A case of double cystic esophageal duplication in VACTERL syndrome: the first case report and a review of the literature

Background

An esophageal duplication cyst (EDC) is a rare malformation resulting from the embryonic foregut. VACTERL syndrome is a genetic disorder affecting many systems of the human body. We report the first case of VACTERL syndrome associated to asymptomatic double EDC.

Case report

A girl with anorectal malformation and rectovestibular fistula, kidney malformation, and various vertebral defects came to our attention at the time of birth. VACTERL disease was diagnosed. She underwent Peña anoplasty at 4 months of life without complications. MRI was conducted at the age of 2. It accidentally showed a double esophageal duplication (12 mm × 35 mm × 10 mm) at the D7-D9 level. We planned a thoracoscopy; previous intraoperative esophagogastroduodenoscopy showed an external compression of the native esophagus. Two duplicated esophageal lesions were removed. The patient made an uneventful recovery and was completely asymptomatic at long-term follow-up.

Conclusions

VACTERL syndrome is still a not well-defined disease. Based on the current literature, this is the first case of a double esophageal duplication in a patient affected by VACTERL syndrome. According to us, the thoracoscopic approach of esophageal duplications can be followed by experts. Complete surgical excision is possible even if the cyst shares a common muscular wall with the esophagus. For this reason, we suggest to close the muscular wall by a simple interrupted suture.

Pulmonary arterial hypertension: guidelines and unmet clinical needs

The term pulmonary arterial hypertension (PAH) identifies a heterogeneous group of diseases characterized by a progressive increase in pulmonary arterial resistance (PVR), which causes a significant burden in terms of quality of life, right heart failure and premature death. The pathogenesis of PAH is not completely clear: the remodeling of the small pulmonary vessels is crucial, causing an increase in the resistance of the pulmonary circle. Its diagnosis is based on cardiac catheterization of the right heart. According to the present hemodynamic definition of pulmonary hypertension (PH) proposed by the Guidelines of the European Society of Cardiology/European Respiratory Society (ESC-ERS), the mean pulmonary arterial pressure (mPAP) values are ≥25 mmHg. In case of PAH, apart from an mPAP value ≥25 mmHg, patients must have a >3 Wood units increase in PVR and normal pressure values of the left heart. PH is a pathophysiological condition observed in more than 40 different diseases, while PAH is a primary disease of the pulmonary bloodstream potentially treatable with specific drugs. PAH is a severe complication of systemic sclerosis (SSc) affecting about 10% of the patients. Due to the devastating nature of SSc-PAH, there is a clear need to systematically adopt appropriate screening programs. In fact, despite awareness of the negative impact of SSc-PAH on quality of life and survival, as well as on the severity of lung function, at the moment standardized and shared guidelines and/or screening programs for the diagnosis and the subsequent early treatment of PAH in SSc are not available. The aim of the present paper is to highlight the lights and shadows of SSc-PAH, unraveling the unmet clinical needs on this topic with a proposal of clinical-diagnostic and therapeutic guidelines.

Isolated Vaginal Agenesis Associated with Multiple Gastrointestinal Anomalies: A Case Report

More than 50% of infants with esophageal atresia have associated anomalies. We present a case report of a 46XX neonate with long-gap esophageal atresia and tracheoesophageal fistula (EA/TEF), anorectal malformation, bowel duplication and vaginal agenesis. This is an unusual association of abnormalities which had not yet described in literature.

Prolonged Remission of Neuro-Behcet Disease following Autologous Transplantation

Two young male patients with severe progressive Behcet's disease with neurological involvement (N-BD) were treated by high-dose immunosuppressive chemotherapy (HIC) followed by autologous CD34+ selected peripheral blood stem cell transplantation (APBSCT). Neurological impairment and disability were quantified by means of Expanded Disability Status Scale (EDSS). Neuroimaging included spine and brain MRI and brain SPECT by radiolabeling technetium (Tc99m) Ethyl Cisteynate Dimer (ECD). Disease progression halted after treatment in both patients. At 48 months of follow-up they were therapy-free and one showed neurological status and disability improvement. Brain MRI findings were unchanged in both patients, but SPECT-ECD showed an increase of blood flow in the hypoperfused cerebral areas in the ameliorated patient. Immune ablation followed by APBSCT can modify the course of severe N-BD. Because of the high risk and the transplant-related mortality, these cases have to be carefully selected.

Continence and quality of life with the modified Heitz-Boyer-Hovelacque rectal bladder for children with urinary incontinence following bladder exstrophy

BACKGROUND

Bladder exstrophy and epispadias are severe congenital anomalies associated with an open bladder and urinary sphincter. Despite modern reconstruction, there is a significant incidence of residual or recurrent urinary incontinence that impacts on quality of life (QoL) and self-esteem, which in turn limits social interaction (Figure). The present study involved 14 patients, mainly from a Middle Eastern country, and reported the early findings with a modification of the Heitz-Boyer-Hovelacque rectal bladder technique for both urinary and faecal control.

STUDY DESIGN

Fourteen children, with a median age of 8.1 years, with poor quality of life and low self-esteem because of urinary incontinence and small polypoidal open bladders of 5-15 ml volume, mostly after bladder exstrophy surgery, were managed with a modification of the Heitz-Boyer-Hovelacque rectal bladder technique keeping an intact anal sphincter. The retrorectal pulled-through colon was anastomosed to the posterior wall of the rectum just above the external sphincter complex, thereby avoiding any possible injury to the anal sphincter. All patients had a normal colon and a competent anal sphincter without lumbosacral spinal or nerve anomalies.

RESULTS

Ten children had a 5- to 10-year follow-up, one child had a 15-year follow-up, and three others, that were also continent, were excluded because of a <5-year follow-up. There were no postoperative complications, and all were dry and odour-free by day within 2-4 weeks of surgery. Two children still had minor urinary loss at night. There were no UTIs and renal function remained unimpaired. Eleven years after surgery, one child underwent excision of a pedunculated benign inflammatory polyp from the tip of the left ureter because of recurrent torsion and bleeding, there was no recurrence at the 2-year follow-up. None of the rectal or ureteric biopsies from any of the children showed metaplasia or neoplasia; however, in view of the potential long-term risks, all children were placed on a lifelong 'proctoscopy and biopsy' protocol.

DISCUSSION

The ability to be dry and odour-free, and to wear normal clothing had a striking impact on QoL and psychological well-being of the children and their families. This was reflected in their positive overall approach, voluntary school attendance, and enthusiastic participation in communal events. All agreed that their improved genital appearance markedly contributed to their better body image and increased self-esteem.

CONCLUSION

These significant benefits, at a crucial time in the child's life, outweigh the potential risk of long-term neoplasia. Therefore, the Heitz-Boyer-Hovelacque rectal bladder technique is recommended with long-term proctoscopic follow-up.

Association of Duodenal Atresia, Malrotation, and Atrial Septal Defect in a Down-Syndrome Patient

Duodenal atresia is the frequent cause of neonatal intestinal obstruction. The association between duodenal atresia, intestinal malrotation, cardiac anomalies and Down syndrome is infrequently reported. We present a prenatally suspected case of duodenal atresia which was associated with malrotation and atrial septal defect in a patient of Down syndrome. Duodenotomy and resection of web was performed in addition to Ladd's procedure. Postoperative course remained uneventful.

Digital ulcers in scleroderma patients: A retrospective observational study

BACKGROUND

The guidelines for digital ulcers (DUs) management in systemic sclerosis (SSc) indicate the use of iloprost to induce wound healing and bosentan to prevent the onset of new DU. The aim of our study was to evaluate whether the combination treatment may surmount the effect of the single drug.

METHODS

We analyzed data regarding 34 patients with SSc and at least one active DU persisting despite 6 months of iloprost therapy, and treated for other 6 months with a combination therapy, i.e. iloprost plus bosentan.

RESULTS

Overall, patients initially presented 69 DUs (58 on the fingers and 11 on the legs). At the end of the study 34 (49.3%) DUs were completely healed (responding, R), 18 (26.1%) started the healing process (partially responding, PR), and 17 (24.6%) did not respond (NR) to therapy. No new DU was recorded and the ulcers localized on the legs did not respond to the combination therapy. Finally, data have been analyzed by dividing the patients in two groups according to the fibrosis level on the finger. In the group with mild fibrosis, 83.4% of DUs resulted with showing complete healing while, in the group with severe fibrosis, only 18% of DUs were healed (P = 0.024).

CONCLUSION

The treatment with iloprost plus bosentan is effective in determining healing of DUs in SSc patients with mild digital skin fibrosis. Conversely, the severity of skin fibrosis strongly influences the healing process of DUs. The study confirmed the efficacy of bosentan to prevent onset of new DUs.

Ultrasound signs of pulmonary fibrosis in systemic sclerosis as timely indicators for chest computed tomography

OBJECTIVES

Systemic sclerosis (SSc) patients in the early stages of pulmonary fibrosis (PF) often have few or no symptoms, normal to borderline pulmonary function tests, and negative chest X-ray (CXR); high-resolution computed tomography (HRCT) is the only reliable means of detecting the early signs of PF. However, thoracic ultrasound (TUS) enables detection of pleural thickening, pleural/subpleural nodules, and other subpleural lung abnormalities across 70% of the subpleural surface. We reassessed concordance between TUS abnormalities and HRCT findings in SSc patients, to see whether TUS pleural line thickness (normally <3.0 mm) could be used to earmark those with asymptomatic PF for timely HRCT assessment.

METHOD

In total, 175 SSc patients (nine males, 166 females), aged 46.46±15.33 years, were given CXR, TUS, HRCT, echocardiography, and pulmonary function tests.

RESULTS

In the 26 patients without HRCT signs of PF, pleural line thickness was ≤3.0 mm. In diffuse SSc, 97/137 patients showed pleural line thickening (between 3.0 and 5 mm) and subpleural nodules in 32/97; and 35/137 showed major pleural line thickening (≥5.0 mm) with nodules, with good concordance with HRCT patterns indicating lung fibrosis severity. HRCT was normal in 5/137, with pleural line thickness≤3.0 mm.

CONCLUSIONS

TUS imaging of pleural/subpleural structures can detect ultrasonographic signs of initial PF prior to the onset of respiratory symptoms and function test abnormalities and, together with current criteria, could thereby enable exclusion of PF in SSc patients. Indicating some patients for selective referral to HRCT can thereby delay unwarranted procedures, provided that pulmonary function and TUS images are stable.

Herlyn-Werner-Wunderlich syndrome: An "early" onset case report and review of Literature

•

We describe a case of a 3 years old girl, with all features of Herlyn–Werner–Wunderlich syndrome (HWWS) who came to our attention for lower abdominal mass.

•

Only six cases are reported in Literature with early onset of this syndrome under 5 years.

•

The aim of this article is to share our experience and focus the attention on the importance of high level of suspicion of HWWS in neonatal period to early diagnosis and treatment.

•

The possible early presentation of this syndrome should be suspected in all neonates (females) with renal agenesia confirmed postnatally or with prenatal diagnosis.

•

An error of evaluation with planning of removal of mass, that can damage patients in term of chance for a successful reproductive outcome.

•

Our team consider HWWS as differential diagnosis in newborn with prenatal ultrasonography of a cystic mass behind the urinary bladder in the absence of a kidney and plan a pelvic ultrasound (with aim to identify an uterus, normal or dydhelfus, and presence or absence of pelvic mass), an examination under anesthesia and cisto-vaginoscopy, if it is necessary. A high level of suspicion, indeed, is the key to early diagnosis.

Herlyn–Werner–Wunderlich syndrome (HWWS) is a rare congenital mullerian anomaly consisting of uterus didelphys, hemivaginal septum, and unilateral renal agenesis [1,2]. Most authors reported cases of Herlyn–Werner–Wunderlich syndrome with prepuberal or postpuberal onset with cyclical abdominal pain and a vaginal mass (3–8). Only six cases are reported in Literature with early onset of this syndrome under 5 years (9–14). Our case is about 3 years old girl, with all the features of this syndrome who came to our attention for lower abdominal mass. The aim of this article is to share our experience and focus the attention on the importance of high level of suspicion of HWWS in neonatal period to early diagnosis and treatment. The possible early presentation of this syndrome should be suspected in all neonates (females) with renal agenesia confirmed postnatally or with prenatal diagnosis. It is common, in fact, an error of evaluation with planning of removal of mass, that can damage patients in term of chance for a successful reproductive outcome. For all these reasons, our team consider HWWS as differential diagnosis in newborn with prenatal ultrasonography of a cystic mass behind the urinary bladder in the absence of a kidney and plan a pelvic ultrasound (with aim to identify an uterus, normal or dydhelfus, and presence or absence of pelvic mass), an examination under anesthesia and cystoscopy and vaginoscopy, if it is necessary. A high level of suspicion, indeed, is the key to early diagnosis.

Preoperative distraction in children: hand-held videogames vs clown therapy

Anxiety in children undergoing surgery is characterized by feelings of tension, apprehension, nervousness and fear which may manifest differently. Postoperative behavioural changes such as nocturnal enuresis, feeding disorders, apathy, and sleep disturbances may stem from postoperative anxiety. Some Authors pointed out that over 60% of children undergoing surgery are prone to developing behavioural alterations 2 weeks after surgery. Variables such as age, temperament and anxiety both in children and parents are considered predictors of such changes.1 Studies were published describing how psycho-behavioural interventions based on play, learning and entertainment in preparing children for surgery, may reduce preoperative anxiety. Clown-therapy is applied in the most important paediatric facilities and has proved to diminish children's emotional distress and sufferance, as well as consumption of both analgesics and sedatives and to facilitate the achievement of therapeutic goals. The aim of our study was to evaluate the efficacy of clown-therapy during the child's hospital stay, with a view to optimizing treatment and care, preventing behavioural alterations and enhancing the child's overall life quality.

Evaluation of subclinical endometritis and consequences on fertility in piedmontese beef cows

Subclinical endometritis (SEM) is poorly investigated in beef cows, as stated in the literature. This project aims to evaluate the rate and the consequences of SEM in Piedmontese cows, with a focus on bacteriological findings and fertility parameters. Uterine cytology was performed for 97 subjects; a total of 31% of the cows were diagnosed as being positive for SEM and as having an 8% neutrophil (PMN) presence on the slide, which is considered as the best cut-off to diagnose the pathology. Only 13% of the cows positive for SEM were pregnant within 130 dpp and generally showed increases of 40 days in the partum to conception interval compared with the negative cows (142 vs 182, p = 0.01). Cows positive for both bacteriology and cytology showed a lower fertility than cows with only inflammation or only a bacterial presence (p = 0.0004). Bacterial isolation detected different species, but no difference in regard to the impact of these bacteria on SEM was shown. Parity, presence of calves, hygiene condition, age and number of service did not affect whether a cow was positive for subclinical endometritis (p < 0.05). The housing system (free stalls vs tie stalls) used seems to affect the SEM rate in Piedmontese cows; cows bred in tie stalls were more likely to be positive for SEM (OR = 2.2; p = 0.04). In conclusion, cytology seems to be a good technique for the diagnosis of subclinical endometritis in beef cows, and as in dairy cows, subclinical endometritis has a detrimental effect on fertility, causing an increase in partum to conception and a decrease in the rate of cows who become pregnant within 130 dpp, particularly for those cows housed in a tie stall.

Uncommon surgical emergencies in neonatology

Objective. Over the past decade, multiple factors have changed the pattern of neonatal surgical emergencies. An increase in prenatal screenings and the development of neonatal tertiary care centres have changed the clinical approach to these kids. Materials and methods. Between 1995 to 2011 were retrospectively reviewed 34 patients with diagnosis of uncommon rare neonatal surgical emergencies at our institute. We analyzed: sex, gestational age, weight at birth, primary pathology, prenatal diagnosis, associated anomalies, age and weight at surgery, clinical presentation, start of oral feeding and hospitalization. The follow-up was performed at 6,12, 24 and 36 months. Results. There were 21 male and 13 female. The gestational age ranged between 28 and 36 weeks. The weight at birth ranged between 700 and 1400 grams. Oral feeding was started between 4th and 10th postoperative day. The average hospitalization was about 70.47 days. To date, all patients have finished the followup. They are healthy. Conclusion. The outcome of the patients with uncommon surgical emergencies is different based on the etiology. Overall survival is generally good but is influenced by the associated anomalies.

Cervical Lymphadenitis by Mycobacterium triplex in an Immunocompetent Child: Case Report and Review

Mycobacterium triplex was first described in 1996. This nontuberculous Mycobacterium causes a severe pulmonary disease in immunocompromised patients but it can involve also healthy patients. A literature search was made on the PubMed database and it produced only few cases of children with cervical lymphadenitis due to this Mycobacterium Triplex. We are describing a case of M. triplex cervical lymphadenitis in an immunocompetent child.

Ileostomy in extremely low birth weight and premature neonates

AIM

The establishment of an ileostomy is a surgical option in the treatment of neonatal intestinal diseases, such as necrotizing enterocolitis (NEC) and meconial disease, in premature or extremely-low-birth-weight (ELBW) infants.

METHODS

A prospective study was performed between July 2000-April 2011, with in exam all cases of acute abdomen in newborn premature babies. We perfomed a temporary ileostomy with a skin bridge and resection of the necrotic intestine. The temporary ileostomy was followed by anastomosis and the effect of possible confounding factors were assessed on the intestinal canalization. Data analysis and multiple monovariate were conducted.

RESULTS

Thirty-three neonates, 14 males and 19 females, operated for intestinal perforation were identified. They were ELBW or premature neonates. There were 24 neonates with NEC, 4 with meconium peritonitis and 5 with complicated meconium ileus. In 4 cases of meconium ileus we found ileale atresia. Eight patients were excluded from the study because 3 died; 2 had cystic fibrosis and 3 with hydrocephalus. Thirteen patients developed complications: 7 related to ileostomy, 2 cholestasis and 4 recurrent NEC. Patients with meconium ileus gain rcovery of bowel function 4 days or more the others (OR=8.0; P=0.0455).

CONCLUSION

In our experience, the establishment of ileostomy for the treatment of acute abdomen in child newborn premature or low birth weight allows optimal management of the child, excluding bowel sick and faster healing with a low rate of morbidity and mortality.

Role of mini-invasive surgery in the treatment of enteric duplications in paediatric age: a survey of 15 years

BACKGROUND

Gastrointestinal tract duplications (ATD) are rare malformations that occur with an incidence of 1 in 4000-5000 live births, with heterogeneous clinical pictures in relation to the different location and size. The purpose of this study was to analyze the role of minimally invasive surgery in the management of ATDs, through a critical analysys of 15 years of experience of the Department of Paediatric Surgery, University of Bologna.

METHODS

The medical records of 22 children diagnosed with ATDs were retrospectively reviewed (January 1995-August 2010). The study analyses: clinical presentation, preoperative diagnosis, site, anatomic type, treatment, and outcome.

RESULTS

Children were 16 males and 6 females, with age ranged from 1 day to 10 years. 20 ATDs (91%) were cystic type, while 2 cases (9%) were tubular one. During the first period of our experience, 10 (45.5%) cases were approached with an open surgery. Then subsequent 8 (36.4%) cases were treated with a diagnostic laparoscopy. This approach permitted also to perform a minilaparotomy, close to the site of the malformation, with a short length of the scar. In 2 cases (9%), we realized an ileal resection with end-to-end anastomosis with a trans-umbilical video-assisted procedure. In 2 cases (9%), we performed a complete removal of the lesions, after complete ligation of the vascular pedicle through a laparoscopic approach. 10 cases (45.5%) were located in the ileum, 6 cases (27.3%) were esophageal duplication, 3 cases (13.6%) were gastric duplications, 2 cases (9%) were located in the colon-rectum. The postoperative course was uneventful in all the cases.

DISCUSSIONS AND CONCLUSIONS

this study shows how, in the management of intestinal duplications, a mininvasive approach, is increasingly taking the field, along with increasing the "learning curve" with laparoscopy. In experienced hands, the laparoscopic approach allows an accurate definition of the exact site of duplication and a miniinvasive treatment with similar principles of open techniques.

Surgical management of congenital chylothorax in children

PURPOSE

Aim of the study was to determine the role of surgery in the management of congenital chylothorax (CC).

METHODS

We retrospectively reviewed the data of patients with CC requiring medical or surgical treatment postnatally in our institution between January 2001 and March 2009.

RESULTS

Ten patients were treated for CC. We divided our population into 2 groups: group A consisted of patients in whom CC healed after conservative medical treatment (thoracocentesis, pleural drainage, total parental nutrition, somatostatin, intrapleural injections of povidone-iodine), and group B of patients who needed both medical and surgical treatment (pleural abrasion and/or pleurectomy). Conservative postnatal therapy was successful in 50% of cases. Of the 3 patients treated preoperatively with intrapleural injections of povidone-iodine, 2 presented with severe complications. Surgical treatment was successful in all cases, with no surgical complications. Patients in group B had a significantly lower birth term (p=0.0254) and birth weight (p=0.0021) compared to patients in group A. Patients with a massive chylothorax (≥50 mL/kg/day) needed surgery significantly more often than those with chylothorax <50 mL/kg/day (p=0.0119).

CONCLUSION

The initial postnatal medical management of CC should consist of thoracocentesis, drainage by tube thoracostomy, and total parenteral nutrition. If this treatment fails after 10 days, we propose using alternative therapies such as somatostatin (although its efficacy is not clear) and surgery. Chemical pleurodesis by intrapleural injection of povidone-iodine must be avoided in infants and small babies. Surgical management by pleural abrasion and/or pleurectomy appears to be safe and effective. Early surgical management is proposed for babies with low birth term, birth weight and massive chylothorax >50 mL/kg/day. Long-term follow-up is needed to evaluate the potential consequences of this therapy.

Idiopathic spontaneous intestinal perforation: a distinct pathological entity in the preterm infant

AIM

Necrotizing enterocolitis (NEC) is the most common cause of intestinal perforation in newborn children. A novel condition of idiopathic spontaneous intestinal perforation (SIPI) was recently described, which does not show clinical and diagnostic features of NEC. The aim of the present study was to define clinical peculiarities and potential risk factors in newborns by comparing SIPI and NEC patients.

METHODS

In the last six years, 85 preterm infants have necessitated surgical counseling for acute abdominal conditions. Among them, 13 underwent emergency surgery, 6 for SIPI and 7 for NEC respectively. Patients were then subdivided into three groups: group 0: 72 infants who did not need surgery; group I: 6 patients with SIPI; group II: 7 patients with NEC. Some variables were retrospectively analyzed and were compared by means of chi(2) test with a significant value of P<0.05.

RESULTS

No association emerged between patient's sex gender (P=0.691), membrane ruptures (P=0.400) and maternal infection (P=0.415). A correlation was observed between pneumoperitoneum and SIPI/NEC (P=0.000). The study on group I and II showed a lower gestational age (27.3 as compared to 30.28 weeks) and a higher number of membrane ruptures (4/6 as compared to 3/7) and of maternal infections (4/6 as compared to 3/7).

CONCLUSIONS

This study showed that a determining factor for the etiopathogenesis of SIPI may be neonatal stress consequent to preterm birth. Infants under 28 weeks of gestational age, with low birth weight, show a particular predisposition to SIPI, with a risk accounting to 96% of the present case series.

Postoperative intestinal obstruction after laparoscopic versus open surgery in the pediatric population: A 15-year review

PURPOSE

The aim of the study was to determine the possible advantages of a laparoscopic approach versus open surgery in infants and children with regard to the development of postoperative intestinal obstruction (PIO).

MATERIAL AND METHODS

A retrospective study was performed. The medical records of all infants and children who underwent an abdominal operation in our department between 1992 and 2007 were included. Data included initial diagnosis, age at initial operation, initial surgical approach, time to PIO, and type of definitive treatment.

RESULTS

From 1992 to 2007, a total of 3 600 abdominal operations were performed in our institution. As not all types of operations can be performed using a laparoscopic approach, in order to obtain a more exact result we compared only operations of the same type performed either by laparoscopy or laparotomy in this period. A total of 2 243 comparable abdominal operations were performed, of which 1 558 (69.46%) were performed using a laparoscopic approach and 685 (30.54%) were performed by laparotomy. Postoperative intestinal obstruction (PIO) was diagnosed in 36 cases. In 14 of these patients (38.88%), the initial operation was performed via a laparoscopic approach, while the remaining 22 (61.12%) were initially operated using laparotomy. Overall, 0.89% of the patients initially managed by laparoscopy and 3.21% of the patients initially treated by laparotomy were treated for postoperative intestinal obstruction (p<0.0001).

CONCLUSION

Abdominal surgery via a laparoscopic approach reduces the likelihood of PIO development. The risk for re-operation after development of PIO in infants and children is significantly higher in patients initially treated by laparotomy than for patients treated by laparoscopy.

[Neonatal neuroblastoma and prenatal diagnosis]

The improvement of the imaging has considerably increased the number of cases of neuoroblastoma, diagnosed in preborn age. The authors present a case of neonatal neuroblastoma diagnosed in prenatal age and managed with a multidisciplinary approach. The authors report the case of R.T., born from a scheduled Caesarean delivery. The echographic morphological prenatal diagnosis showed an abdominal mass of 3x2 cm located on the upper side of the kidney, which was not apparently involved. Postnatal ultrasound evaluations confirmed that diagnosis. The diagnostic programme included nuclear magnetic resonance and a renogramm with metaiodobenzylguanidine. These exams confirmed the presence of a mass, probably due to a neuroblastoma. Due to the increasing of the mass, the patient underwent surgical excision of the neoplastic mass. The histological examination confirmed the diagnosis of neuroblastoma Stage I without medullary involvement. During the operation, a medullary biopsy was performed. The FISH exam did not show the amplification of N-myc or a delection of p36 chromosome. For patients younger than 18 months there is no therapeutic gold standard for the treatment of suprarenal masses of neoplastic origin, and the approach is still controversial. The complete excision of the mass should be taken in consideration in presence of an increasing neoformation, and should not include any chemotherapeutical or radiation therapy for stage I, II, IVs (INSS) or L1, MS (INGRSS) neoformations. In conclusion, the effectiveness of a multidisciplinary approach of neonatal neuroblastoma is higher in the early diagnosis and in an accurate staging of the disease, which is fundamental for the favourable prognosis.

[Collaboration between occupational doctors in the public prevention services and qualified occupational doctors: description of an experience in the sandstone sector of Alto Mugello]

BACKGROUND

The present course of work-related injuries imposes an effective collaboration among public service's doctors and qualified occupational doctors. We refer to a positive interaction in a prevention plan of hand-arm vibrations exposure during phases of dressing in the sandstone sector of Alto Mugello.

METHODS

Both were acquired data on exposition (risk assessment, measures on tools, times and levels of exposition, etc.) and data on workers' health (an high number of workers showed suspect angioneurotic disorders). The symptomatic workers were subjected to a clinical-instrumental examination that highlighted a clear correlation between high hand-arm vibrations exposition and functional injury.

RESULTS

Sharing informations is a precious tool both for Public Prevention Services, it enables in fact to realize an accurate representation of workers' health state, and for qualified occupational doctors to manage risk with employers and to carry out an effective health surveillance.

Topical application of isosorbide dinitrate in patients with persistent constipation after pull-through surgery for Hirschsprung's disease

AIMS

The aim of this study was to evaluate the anal manometric changes and the clinical effects after topical application of isosorbide dinitrate (ISDN) in patients with persistent constipation after pull-through surgery for Hirschsprung's disease (HD).

METHODS

We studied 3 children (2 males and 1 female), aged 2, 3 and 5 years respectively, who had undergone the Soave-Boley surgical procedure for HD and who suffered from persistent constipation after operation. We performed a pre- and postoperative anorectal manometry study and we applied ISDN paste (1 mg/kg two times daily) in the anal region for three weeks. All patients were followed-up and re-evaluated at 1, 3, and 6 months.

RESULTS

All patients showed an improvement of symptoms, with an average of 4 spontaneous evacuations per week. Prior to the topical treatment, the medium pressure was 115.6 mmHg (range 102 - 130 mmHg), the maximum pressure was 160 mmHg (range 145 - 175 mmHg), and the medium length of the high pressure zone was 1.8 cm (range 1.5 - 2.0 cm). At the 6 month follow-up, the medium pressure was 57.3 mmHg (range 52 - 61 mmHg, a decrease of 54.4 %), the maximum pressure was 98 mmHg (range 88 - 107 mmHg; a decrease of 38.7 %), and the medium length of the high pressure zone was 1.6 cm (range 1.4 - 1.8 cm; a decrease of 11.1 %).

CONCLUSIONS

Topical treatment with ISDN is a valid therapeutic alternative to an anal myotomy in patients with persistent constipation after pull-through surgery for HD. However, a greater number of cases and a longer follow-up are necessary to confirm the validity of our experience.

Testicular hypotrophy in varicocele: pre and postoperative echographic follow-up in the pediatric age

AIM

Varicocele is characterised by an anomalous tortuosity and dilation of the veins of the pampiniform plexus. The etiopathogenetic mechanisms are still unclear, but a correlation seems to exist between varicocele and testicular development, with possible repercussions on the testicle's functionality. The aim of this study is to evaluate gonadic trophism through echographic monitoring in the pre and postoperative phases in patients affected by idiopathic varicocele with testicular hypotrophy in order to evaluate the treatment's benefits.

METHODS

Sixty-six patients (mean age 12,5; range 10-17) consecutively operated for left idiopathic varicocele were considered. Of these, 27 had ipsilateral testicular hypotrophy and thus they were included in the study. Fifteen were operated upon in videolaparoscopy (VLS), and 12 by the classic open inguinal access. The mean follow-up was 18 months (6-24 months). The data were analyzed by nonparametric Mann-Whitney U test.

RESULTS

An increase in the testicular volume was observed clinically and by ultrasound in 13 of the 15 patients treated by VLS and in 9 of the 12 patients operated by traditional means. The nonparametric Mann-Whitney U test showed a significativity between pre and post-operative values.

CONCLUSION

The testicular trophic healing observed in 81.5% of the operated patients leads to the belief that an early correction can allow a rapid volumetric increase and an improved function of the gonad.

Myositis ossificans in children: description of a clinical case with a rare localization

Myositis ossificans (MO) also defined as myosteosis or hematoma ossificans, is a benign condition presenting as an heterotopic, well- defined neoformation in muscles and soft tissues. It was first described by Guy Patyn in 1692 and defined in its histopathological aspects by Von Dusch in 1868. It most frequently has a post-traumatic onset (60-75% of cases), usually following small repeated traumas or a single bruising episode. MO is rare in subjects under 10 years of age, whereas it is more frequent in teen-age athletes, and over 50% of cases are diagnosed in the third decade of life. Its etiopathogenesis in unknown, although it is associated with a traumatic event in 75% of cases. MO most common localizations are arms, legs, shoulders and hands, rarely chest. The lesion presents with different degrees of maturation and diagnostic tools are echotomography (ECT) as a primary investigation, and NMR for a better diagnostic assessment. Because of the self-limiting nature of the lesion and its spontaneous resolution, a conservative treatment is advised along with radiological follow-up which is most indicated in the presence of either typical MO features or highly suggestive ECT o NMR findings. In case of uncertain diagnosis, relevant muscular function impairment, considerable lesion dimension or severe pain, exeresis and histological examinations are suggested. The present paper describes and discusses a clinical case of MO in a child, with a rare localization.