Meckel's diverticulum perforation in a newborn positive to Sars-Cov-2

The health emergency linked to the Sars-Cov-2 infection represented an absolutely new problem for all health professionals. In particular, the information regarding the spread of the virus in the pediatric field and its manifestations are still incomplete. In this paper we present a case of neonatal infection which, as far as we know, represents one of the few published cases and which occurred in a patient who came to our attention for acute abdomen from intestinal perforation. The perforation was caused by Meckel's diverticulum, an event considered infrequent in the first year of life and almost exceptional in the neonatal period. This case required particular management, putting pediatric surgeons in front of new and difficult to solve problems. New onset clinical events, such as this one described, represent an opportunity for sharing useful data for the creation of universal protocols for the management of patients with problems that are becoming common and of which little is known.

Staged laparoscopic-assisted endorectal pull-through for long segment Hirschprung's disease and total colonic aganglionosis

AIM

Recently laparoscopic endorectal pull-through (LERPT) has been widely performed for treatment of Hirschsprung's disease (HD) as a one stage procedure. In long segment aganglionosis (LSA) and in case of total colonic aganglionosis (TCA) a staged procedure can be preferred. The authors report their experience in the staged LERPT for LSA and TCA.

METHODS

In the last five years we treated 4 infants (3 male, 1 female) with LSA and TCA. The mean age at presentation was 40 days (2-110 days). In 3 patients we performed in the first step rectal biopsies, multiple laparoscopic biopsies and stoma. In one case ‑ presenting as small bowel obstruction - we performed an emergency laparotomy for ileostomy and biopsies of the bowel. Histology showed 2 left colon aganglionosis (LCA) and 2 TCA. The LERPT was performed at a main age of 10 months. After stoma closure the LERPT was performed according to Georgeson's technique.

RESULTS

There were no intraoperative complications. The patient with previous laparotomy needed conversion because of the abdominal adhesions. The two infants with LCA had preoperative and recurrent postoperative enterocolitis. In one case a successful posterior anorectal myectomy was performed. At follow up the children present constipation. The patient with TCA undergoing to LERPT presents a good frequency of defecation.

CONCLUSION

Our experience, although on limited series, shows that staged minimally invasive surgical treatment can be safely performed in the LSA and TCA, but conversion can be necessary especially in case of previous laparotomy.

Surgical infants on total parenteral nutrition have impaired cytokine responses to microbial challenge

BACKGROUND/PURPOSE

Cytokines are essential for the prevention of microbial infections. Total parenteral nutrition (TPN) in infancy is associated with an increased risk of infection, and this could be related to altered cytokine production. The aim of the study was to determine if cytokine production is altered in monocytes from surgical infants receiving TPN.

METHODS

There were 3 study groups: (a) infants receiving TPN, (b) enterally fed healthy control infants, and (c) enterally fed healthy control adults. Blood samples were incubated with either Escherichia coli LPS, Staphylococcus epidermidis, or with medium alone. Flow cytometry was used to measure monocyte intracellular cytokine: tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-1beta.

RESULTS

After LPS stimulation, the percent of monocytes producing TNF-alpha and IL-6 were lower in infants on TPN than both control infants and adults. This was most apparent for TNF-alpha. The difference for IL-1beta was significant only between infant on TPN and control adults. When blood was stimulated with S. epidermidis, all 3 cytokines were significantly lower in the TPN group compared with control adults. However, the differences between infants on TPN and infant controls only reached statistical significance for IL-6.

CONCLUSIONS

The inflammatory response to bacterial challenge is impaired in infants on TPN compared with enterally fed infants or adults. The pattern of this response may be dependent on the nature of the microbial challenge. Our results indicate that the susceptibility of TPN-fed surgical infants to bacterial infections may in part be caused by impaired cytokine responses after bacterial invasion.

Can histologic changes of the upper pole justify a conservative approach in neonatal duplex ectopic ureterocele?

The aim of this study was to review the histology of the upper-pole segment in patients with duplex-system ectopic ureterocele (DEU) to determine if less aggressive surgery is justified in prenatally-diagnosed cases. The study included 15 consecutive patients with DEU treated between 1991 and 1999. The diagnosis was made according to the criteria of the Section on Urology of the American Academy of Pediatrics. The histology specimens were assessed for dysplastic, inflammatory, and obstructive changes. All 15 patients were surgically treated by heminephro-ureterectomy and the surgical specimens were histologically examined. Nine cases were diagnosed prenatally; the histology of the upper-pole segment in these patients showed segmental renal microcystic dysplasia, chondroid metaplasic islands, and an inflammatory tubulointerstitial nephropathy in 6 (66.6%) and nephroblastomatosis in 2 (22.2%). The histology of the 6 postnatally-diagnosed patients showed segmental multicystic renal dysplasia, inflammatory tubulo-interstitial nephropathy, and segmental parenchymal scars. The upper-pole histology of the prenatally-diagnosed patients did not show any evidence of reversible histologic changes. Considering this findings and the good outcome of patients treated with upper-pole nephroureterectomy, less aggressive surgery with preservation of the upper pole does not seem justified.

Monocyte and neutrophil activity after minor surgical stress

BACKGROUND/PURPOSE

Surgical stress produces changes in the immune status of patients. In adults, major surgery causes immunosuppression, whereas minor operations stimulate immune responses. In children, the immunologic response to surgery has not been elucidated completely. The authors investigated the effects of minor surgery on immune response by analyzing neutrophil and monocyte phagocytosis and oxidative burst activity.

METHODS

Sixteen children undergoing elective minor surgery were enrolled. Blood samples were collected before the operation (at time of induction of anesthesia), at the end of operation, and 72 hours after surgery. Neutrophil and monocyte phagocytosis and oxidative burst activity were studied using a flow cytometric method.

RESULTS

Phagocytosis and oxidative burst increased significantly at the end of the operation, both in neutrophils (7.4% and 14.3%, respectively) and monocytes (11.6% and 27%, respectively). The increase was only significant for monocytes (17.5%) 72 hours after surgery. White cell count did not show any significant changes. There was no significant correlation between phagocytosis, oxidative burst activity, and white cell count or neutrophil and monocyte count.

CONCLUSIONS

This study shows that minor surgery in children induces immune activation by increasing neutrophil and monocyte phagocytosis and oxidative burst activity. Further studies are required to understand the molecular basis of these findings.

[Do histologic changes of the upper renal pole in double ectopic ureterocele justify a conservative approach?]

The aim of this study was to review the histology of the upper pole segment in patients with duplex ectopic ureterocele to verify if a less aggressive surgery is justified in the prenatally diagnosed patients. We reviewed the histology of the upper pole segment of 15 consecutive patients with duplex system ectopic ureterocele treated between 1991 and 1999 at the Paediatric Surgery Unit of University Hospital of Messina. The diagnosis of duplex system ectopic ureterocele was made according to the criteria of the Section on Urology of the American Academy of Paediatrics. The histology specimens were assessed for dysplastic, inflammatory and obstructive changes. All 15 patients with duplex system ectopic ureterocele were surgically treated with heminephro-ureterectomy and the surgical specimens were histologically examined. Nine of the 15 patients were prenatally diagnosed. The histology of the upper pole segment of the 9 prenatally diagnosed showed in all patients segmental renal microcystic dysplasia, chondroid metaplasic islands and an inflammatory tubulo-interstitial nephropathy in 6 patients (66.6%) and in 2 (22.2%) nephroblastomatosis. The histology of six the postnatal postnatally diagnosed patients showed in all patients segmental multicystic renal dysplasia, inflammatory tubulo-interstitial nephropathy and segmental parenchymal scars. The upper pole histology of the patients with duplex ectopic ureterocele diagnosed prenatally did not show any evidence of reversible histological change. Considering the histology and the good outcome of patients treated with upper pole nephroureterectomy a less aggressive surgery with preservation of the upper pole does not seem justified.

Fetal vesicoureteral reflux: neonatal findings and follow-up study

To examine features of primary vesicoureteric reflux (VUR) at birth following prenatal hydronephrosis and to describe the course of congenital damage in the first two years of life. We reviewed the records of 382 patients with prenatally diagnosed dilated urinary tracts seen during a 15-years period. When fetal hydronephrosis was confirmed at birth, voiding cystography was performed. If a VUR was diagnosed dimercaptosuccinic acid (DMSA) renography, at 1 month of age, was also performed. Cystography and DMSA renography were repeated and 1 and 2 years of age. Of 382 patients with prenatal hydronephrosis, 68 (17.8%) had primary VUR (50 male and 18 female, M:F = 3:1). VUR was unilateral in 24 patients and bilateral in 44 for a total of 112 refluxing renal units (RRUs). High-grade VUR (grade > or = 4) was found in 70 (62.5%) RRUs, and 60 (85.7%) were boys. Grade V reflux was observed in 96.5% of males. At birth, 22 (20%) RRUs had moderate impairment of renal function. In 12 (10%) RRUs (grade > or = 4) was demonstrated by a severe decrease in renal function. In all cases no focal scarring was noted. Eight infants (all males), with grade 5 degrees VUR, in the first six months of life had surgical treatment. The majority of the RRUs (110/112 = 89%) were followed medically. Mild reflux (grade I-III) had resolved in 81% RRUs, severe reflux (grade > or = 4) had resolved in 38% RRUs. Serial renal scans during the follow-up showed no progression of renal damage. VUR diagnosed at birth on prenatal ultrasonography is associated with congenital damage, with males affected more often than females. In patients without infection, after two years, modification of renal function or renal scars are very rarely observed.

Pelvic neuroblastoma: low mortality and high morbidity

BACKGROUND/PURPOSE

Cervical, thoracic, and pelvic neuroblastomas are regarded as having a better outcome than abdominal primaries. The aim of the study was to analyze the results of treatment of pelvic neuroblastomas in our institution.

METHODS

The authors reviewed the records of 284 patients with neuroblastoma treated in our hospital during the period 1983 through 1998 and identified 17 (6%) with pelvic tumors. The revised International Neuroblastoma Staging System was used.

RESULTS

There were 6 patients with stage 1 disease, 8 with stage 2, 2 with stage 3, and 1 with stage 4 disease. Intraspinal extension of the tumor was present in 7 patients (41%). Except for one child with stage 4 disease, all patients underwent an attempt of tumor excision, and 6 had a complete resection. All 7 patients with intraspinal tumor survived. Permanent postoperative neurological complications occurred in 6 patients (35%). These included sciatic nerve palsy, urinary and fecal incontinence, neuropathic bladder, and leg weakness or nerve root injury L4-S1. Three of 17 patients died, but 1 fatality was unrelated to the tumor. The overall survival rate was 82% and was not influenced by the completeness of tumor resection.

CONCLUSIONS

The survival of nonmetastatic pelvic neuroblastoma in our institution is good despite incomplete tumor resection. Intraspinal extension is not a negative prognostic factor. Considering the high incidence of permanent neurological damage after surgery and the generally favorable biological characteristics of these tumors, surgical treatment should not be overaggressive.

The neonatal management and surgical correction of urinary hydrometrocolpos caused by a persistent urogenital sinus

OBJECTIVE

To define the neonatal management and ultimate surgical correction via the anterior sagittal transanorectal approach (ASTRA) in cases of neonatal urinary hydrometrocolpos associated with a persistent urogenital sinus (UGS).

PATIENTS AND METHODS

We report three patients with UGS (with no ambiguous genitalia) and urinary hydrometrocolpos in whom prenatal ultrasonography showed cystic dilatation of the pelvis. Two patients were temporarily treated with intermittent vaginal catheterization and antibiotic prophylaxis, and in one a cystostomy was necessary to temporarily drain the urine. At the age of 6-8 months the patients underwent reconstructive surgery of the UGS via the ASTRA, under a previous protective colostomy.

RESULTS

The mean (range) age of the patients at the last follow-up was 18.7 (8-32) months. A good cosmetic result was obtained in all patients. The vagina was dilated briefly with no anaesthesia in each patient. Patients had normal faecal control after the colostomy was closed and none had urinary incontinence.

CONCLUSIONS

When possible, intermittent vaginal catheterization permits sufficient temporary drainage of the urinary hydrometrocolpos associated with a persistent UGS. Subsequent ASTRA allows good exposure of the UGS, assuring the preservation of the anorectal innervation and of the sphincteric mechanism.

[Urinary hydrometrocolpos by persistent urogenital sinus; prenatal diagnosis and neonatal management]

Urogenital Sinus (UGS) malformation can be ascribed to an arrest of normal embryonic vaginal development. Neonates with UGS frequently have ambiguous genitalia, rarely the vulva may be normal. The aim of this work is to define the role of prenatal sonography in the diagnosis of UGS associated with hydrocolpos and/or hydrometrocolpos. The Authors report their experience on 3 cases of UGS without ambiguous genitalia with hydrometrocolpos, in which prenatal sonography had shown a cystic dilatation in the pelvis. After birth the 3 neonates presented with female genitalia and a single orifice between the labia. The pelvis sonography showed in all the cases an hydrometrocolpos with a large vagina and a compressed and anteriorly located bladder. Voiding cystourethrogram, genitography and genitoscopy confirmed the presence of an UGS with urinary retention inside the vagina and stenosis of the distal portion of the vagina itself. An early drainage of the capacious vagina was performed in the three patients. There are very few reports in the literature of UGS with hydrometrocolpos diagnosed in utero. The cystic dilatation of the vagina is always misdiagnosed with a distended bladder. In utero, infact, the bladder can not be identified being displaced anteriorly by the vagina. The presence of a fluid-debris level inside the cystic anechoic mass must be considered a crucial finding. Multiple echoes are due to vaginal secretions. Prenatal ultrasound has then a definitive role in detecting an obstructed genital tract. This allows to rapidly drain the vagina relieving urinary tract obstruction.

[Videourodynamic findings in the child with enuresis]

Videourodynamic investigation was carried on 62 patients with enuresis (34 females, 28 males). Patients were all grouped in four different clinical types according to the International Continence Society: (Type I) monosymptomatic enuresis nocturnal (24 cases); (Type II) nocturnal and diurnal enuresis without daytime frequency (8 cases); Type III) nocturnal enuresis with daytime frequency (22 cases); (Type IV) nocturnal and diurnal enuresis with daytime frequency and/or urgency (8 cases). In children with monosymptomatic enuresis nocturnal the videourodynamic study revealed, in 85% of cases, a normal bladder; in only 17% of cases was observed a detrusor instability. In patients with Type II enuresis a normal bladder was observed in 6 cases, whereas in two a detrusor instability was present. Among the 22 patients with Type III enuresis, 13 cases (59%) had a detrusor instability, 3 cases (14%) had a vesicosfinteric dyssinergia and 6 (27%) had a normal activity. In this group of patients it was documented in 10 cases a trabeculated bladder together with a vesicoureteral reflux in 4 patients, meatal stenosis and bladder diverticula in other two cases. All patients with Type IV enuresis documented pathological data: detrusor instability in 4 patients, vesico-sfinteric dyssinergia in two and neurogenic non-neurogenic bladder in the other two cases. A severe trabeculated bladder was present in all this cases, with vesico-ureteral reflux in two patient. Maximum cystometric capacity was low in 41 cases (66%), normal in 20 (32%), high in 1 (2%), independently of the types of enuresis.