Effectiveness of unilateral sequential video-assisted sympathetic chain blockage for primary palmar hyperidrosis in children and adolescents

INTRODUCTION

Primary palmar hyperhidrosis (PPH) is a severely debilitating condition that can affect patients of any age. Thoracoscopic sympathectomy provides a definitive treatment for PPH. Aim of this study is to investigate the effectiveness of unilateral sequential video-assisted thoracic sympathetic chain clamping (VATSCC) by clips application in pediatric population.

METHODS

The surgical procedure was done in the semi-sitting position, under general anesthesia with orotracheal intubation. Mean operation time was 23 ± 6 min (range 12-45). Two 5 mm ports were inserted at the level of the middle axillary line in the second and fourth intercostal space respectively. The sympathetic chain was identified, and two clips were applied, the first one at the level of the third and the second one, at the level of the fourth rib. No chest tube was used. Resolution of symptoms, complications, recurrence rate, onset and duration of compensatory hyperhidrosis were analyzed.

RESULTS

From August 2017 to September 2021, 58 patients (male:female ratio 32:26), mean age 16.5 years (range 14-19), with PPH underwent unilateral sequential VATSCC by clips application, starting on the dominant hand. The contralateral side was operated 2 months after. All patients except one (transient pneumothorax) were discharged on the first post-op day. No immediate or late complications have been recorded. Mean follow-up was 32 months (range 6-41). All patients except one (1,7%), affected by Raynaud's disease, showed a complete resolution of the symptom. Seven patients (12%) developed transient moderate compensative hyperhidrosis (CH) that spontaneously disappeared in the postoperative period.

CONCLUSIONS

Unilateral sequential thoracoscopic sympathetic chain clamping for PPH in pediatric patients is a safe and very effective procedure with a low complication rate and low incidence of postoperative CH that, in our experience, resolved spontaneously in the postoperative period, after the second surgery leading to an improvement in the quality of life.

Subtotal functional sialoadenectomy vs four-duct ligation for the treatment of drooling in neurologically impaired children: Long-term follow-up

OBJECTIVES

The best surgical option to treat drooling in neurodisabilities is still under debate. The aim of this study was to describe the technique of subtotal functional sialoadenectomy (SFS) (ie four-duct ligation (4-DL) together with bilateral sublingual gland excision) and its long-term outcomes, in comparison with 4-DL.

DESIGN

Retrospective observational cohort study.

SETTING

Unit of Pediatric Surgery of Bambino Gesù Children's Hospital (Rome).

PARTICIPANTS

Seventy-five patients surgically treated for drooling between 2002 and 2012, with at least five years of follow-up, divided into two groups: 4-DL group (19 patients) underwent four-duct ligation, and SFS group (56 patients) underwent subtotal functional sialoadenectomy.

MAIN OUTCOME MEASURES

Primary end points were the evaluation of drooling improvement after surgery (parameters: Drooling Severity and Frequency Scale, DSFS; no of bibs/day; no of shirts/day; no of pneumonia/year; use of antidrooling drugs) and the comparison between two different surgical techniques.

RESULTS

Median age at surgery was 10 years (1-35). Long-term outcomes showed significant improvement in DSFS and in no of shirts/day in both groups. Significantly better results were found in the SFS group than in the 4-DL group as far as DSFS (P value .045), no of bibs/day (P value .041), no of shirts/day (P value .032) are concerned. Reoperation rate for recurrence was 42% in the 4-DL group and 0% in the SFS group (P value < .0001). Six patients (8%; 2 in the 4-DL group and 4 in the SFS group) experienced perioperative complications, while 4 patients (5%; 2 in the 4-DL group and 2 in the SFS group) recorded long-term complications, with no difference between groups neither need for surgical treatment. No surgery-related mortality was recorded.

CONCLUSIONS

In our experience, subtotal functional sialoadenectomy ensured significantly greater long-term effects than four-duct ligation for drooling treatment in neurologically impaired child, with equal complication rate.

The Obalon swallowable intragastric balloon in pediatric and adolescent morbid obesity

Background and study aims Incidence of morbid obesity has grown dramatically in the last half century and this phenomenon affects with particular severity the pediatric population. Dietary restrictions and careful programs to improve lifestyle are often ineffective to manage this particular group of patients, due to poor compliance typical of the adolescence. The aim of this study was to evaluate the effectiveness of a new intragastric balloon for treatment of morbidly obese children. Patients and methods A new swallowable intragastric balloon (Obalon) has been used for the first time in 17 obese children in order to assess its safety and effectiveness in terms of reduction in excess weight. In 9 of 17 children a second balloon was placed 30 to 40 days after the first insertion. All devices were endoscopically removed after a mean time of 18 weeks. Results In the group of 16 patients who completed the study (1 patient still under treatment) mean weight decreased from 95.8 ± 18.4 Kg to 83.6 ± 27.1 (P < 0.05). Mean body mass index (BMI) decreased from 35.27± 5.89 (range 30.4 - 48) to 32.25 ± 7.1 (range 23.5 - 45.7) (P > 0.05); mean excess weight, calculated according to Cole's curves for pediatric populations, decreased from 36.2 ± 15.9 to 29.4 ± 18.3 Kg (P = 0.14), with an %EWL of 20.1 ± 9.8 (range 2.3 - 35.1). Waist circumference decreased from 109 ± 12.3 cm to 99 ± 10.5 cm (P < 0.05). Conclusions Obalon can be administered easily without complications, inducing an appreciable weight loss with a statistically significant reduction in BMI and an improvement in associated comorbidities.

YouTube and pediatric surgery. What is the danger for parents?

Internet became one of the most important sources of public health informations especially for relatives and/or caregivers of sick children. Use of YouTube as a source of information in pediatric surgery has not been evaluated. In this study, we want to evaluate the use of YouTube as a source of information about one of the most frequent surgical urgency in pediatric patients, the acute appendicitis, to evaluate the risks for patients and parents.

Role of surgery in pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) has a more extensive and progressive clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent surgical treatments are needed. The therapeutic goal is to gain clinical and laboratory control of the disease with minimal adverse effects while permitting the patient to function as normally as possible. Approximately 5-10 % of patients with UC require acute surgical intervention because of fulminant colitis refractory to medical therapy. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This review will focus on the current issues regarding the surgical indications for pediatric UC, the technical details of procedures and results of most recent published series to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

Segmental haemorrhagic infarction of the testis in a paediatric patient: a rare aftermath of epididymitis

Testicular infarction is an uncommon finding in paediatric age and is usually due to testicular torsion or trauma causing venous rupture with thrombosis and/or arteriolar obstruction. Other causes of segmental infarction of the testes are represented by polyarteritis nodosa, thromboangioiitis obliterans and hypersensitivity angiitis. A few cases of testicular infarction due to epididymitis have been described in the literature related mainly to adult patients. Epididymitis is usually treated in the outpatient setting with close follow-up, but according to our present experience, and reviewing the literature, there may be some cases in which, surgical exploration is mandatory in order to avoid testicular damage.

BioEnterics intragastric balloon for treatment of morbid obesity in Prader-Willi syndrome: specific risks and benefits

BACKGROUND

Obesity in Prader-Willi Syndrome (PWS) is progressive, severe, and resistant to dietary, pharmacological, and behavioral treatment. A body weight reduction is mandatory to reduce the risk of cardio-respiratory and metabolic complications. The aim of the study was to assess risks and benefits of BioEnterics Intragastric Balloon (BIB) for treatment of morbid obesity in PWS patients.

METHODS

Twenty-one BIB were positioned in 12 PWS patients (4 M, 8 F), aged from 8.1 to 30.1 years, and removed after 8 +/- 1.4 months (range: 5-10 months). Auxological, clinical, and nutritional evaluations were performed every 2 months. Variations in body composition were analysed by dual energy X-ray absorbiometry (DXA).

RESULTS

One patient (28.5 years, BMI: 59.3 kg/m(2)) died 22 days after BIB positioning because of gastric perforation. In another case (26.2 years, BMI: 57.6 kg/m(2)), BIB was surgically removed after 25 days because of symptoms suggesting gastric perforation (not confirmed). The remaining ten patients showed a significant decrease of BMI (p = 0.005) and of fat tissue as measured by DXA (p = 0.012). No significant modifications in bone mineral density (BMD) occurred, but a slight loss in lean body mass (p = 0.036) was documented. In five patients, BIB treatment was repeated more than once.

CONCLUSION

This study shows that when noninvasive pharmacological therapies fail, BIB may be effective to control body weight in PWS patients with morbid obesity, particularly when treatment is started in early childhood. However, careful clinical follow-up and close collaboration with parents are crucial to avoid severe complications, which can be caused by persisting unrestrained food intake.

Role of cyclosporin in preventing or delaying colectomy in children with severe ulcerative colitis

BACKGROUND

Oral cyclosporin (CyA) has been widely and successfully used in adult patients with severe ulcerative colitis (UC) to delay or avoid colectomy.

AIM

To determine if treatment with oral CyA is similarly effective in pediatric patients

MATERIALS AND METHODS

Data on all patients with severe UC treated with oral CyA in our unit were collected retrospectively. Patients were treated with CyA if dependent on or resistant to steroids, and therefore, candidates for colectomy.

RESULTS

Thirty-two patients with severe UC were treated with CyA administered orally at a dose needed to obtain therapeutic blood levels (150-250 ng/ml). Twenty-eight of 32 patients (87%) had an immediate response within 11 days. Four (13%) did not respond and underwent colectomy. One patient had two cycles of treatment and is in remission. Two patients underwent three cycles of treatment because of relapse, but both eventually underwent elective colectomy. Three other patients underwent elective colectomy. A total of nine colectomies were performed.

CONCLUSIONS

Treatment with oral CyA altered the course of UC in 28/32 (87%) of patients; 4/32 (13%) did not respond to oral CyA and underwent colectomy. Of the 28 patients that responded to CyA, five underwent later elective colectomy. Overall, in 72% of patients, colectomy was avoided. We, therefore, suggest a trial of oral CyA in all children with severe UC who are dependent or resistant to corticosteroids.

Surgery in disabled children: general gastroenterological aspects

Cerebral palsy (CP) is a non-progressive but not unchanging disorder of movement and/or posture, due to an insult to or anomaly of the developing brain. Gastrointestinal surgery can play a role in the treatment of pathologies frequently associated with a condition of neurological impairment such as gastro-oesophageal reflux disease (antireflux procedure), feeding difficulties (percutaneous endoscopic gastrostomy/jejunostomy) and swallowing difficulties (ligation of salivary gland ducts). Gastro-oesophageal reflux occurs in up to 70-75% of children with cerebral palsy. Children with gastro-oesophageal reflux disease (GERD) may present with feeding difficulties, recurrent vomiting and recurrent chest infection associated with poor growth and nutrition, reactive airway disease particularly nocturnal asthma, choking attacks, anaemia, and wheezing. Nutritional deprivation in children with cerebral palsy is the summation of several factors which result in reduced intake. Percutaneous endoscopic gastrostomy (PEG) has radically changed the handling of children with nutritional problems who, before the introduction of this procedure, were force fed parenterally or enterally, by nasogastric tube, conventional surgical gastrostomy or central venous access. In children with CP, PEG is the preferred technique for long-term enteral feeding. Swallowing dysfunction is the main cause of drooling in cerebral palsy, and medical treatment is often inefficient. Surgical treatment involves neurectomy, translocation of the salivary duct, salivary gland resection or salivary duct (parotid and submandibular) ligation.

CONCLUSION

This review focuses on the role of surgery in managing gastrointestinal aspects in children with CP and, in particular, surgical experience at our department with fundoplication, PEG placement and ligation of salivary ducts.

Surgery for ulcerative colitis in pediatric patients: functional results of 10-year follow-up with straight endorectal pull-through

Children and adolescents affected by ulcerative colitis (UC) frequently require colectomy because of refractory or chronic symptoms. The aim of this paper is to present our experience and 10-year follow-up results of 28 patients who underwent endorectal pull-through (ERPT) as surgical treatment for UC, with special regard to surgical complications, stooling patterns (frequency of defecation, stool consistency, urgency period), fecal incontinence, and quality of life. A retrospective chart review of these patients was performed to evaluate age at colectomy, indication for surgical treatment, operative procedures, technical details, and early or late complications. Frequency of defecation was less than twice per day in two patients, between three and five times per day in nine patients, and more than six times per day in 10 patients. Stool consistency was normal in 14 patients, loose in five, and liquid in only two cases. Urgency period was normal (minutes) in 14 patients, short (seconds) in four, and absent in three. Ten patients (47%) have perfect or good fecal continence, whereas 11 (52%) patients present moderate to total incontinence. The self-reported emotional health was good in most of the patients. A large number are progressing well at school and are coping with their operations. Studies of quality of life in UC patients who underwent surgical treatment in childhood or adolescence, comparing as well the results according to the surgical technique adopted, must be encouraged.

A prospective randomized clinical trial on pain control after major abdominal surgery

This study was conducted in order to investigate the advantages and limitations of four analgesic modalities: a) epidural morphine; b) intravenous morphine; c) patient controlled intravenous morphine (patient-controlled analgesia); and d) non-steroidal anti-inflammatory drugs. Eighty patients undergoing major abdominal surgical procedures were prospectively and randomly treated with one of the above-mentioned analgesic methods. Evaluation of pain perception was done using the visual analogue pain score and the simple descriptive scale 4 hours after the procedure, in the early morning on postoperative day 1 and in the afternoon on postoperative days 1, 2 and 3. The need for supplementary analgesia and the onset of complications, if any, were also evaluated for each patient. Patient-controlled intravenous morphine yielded the best analgesic effect over the entire period. Epidural morphine was more effective in the very early postoperative period compared to modalities (b) and (d). Non-steroidal anti-inflammatory drugs, on the other hand, were more effective on the later postoperative days. None of the patients in group C needed supplementary analgesia, as against 20% in group A, 55% in group B and 40% in group D. Patients with hypochondriasis scores > 70 or depression scores > 70 required supplementation of analgesia more often. Morphine proved to be the drug of choice. Drug titration may be modulated in relation to the psychological characteristics of the patient. The best drug titration modality, in fact, is patient-controlled analgesia.

The role of transanal endorectal pull-through in the treatment of Hirschsprung's disease - a multicenter experience

The transanal approach (TAA) is a new technique for surgery of Hirschsprung's disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1-72 months. In 14 children the TAA only was performed; in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending.

Surgical treatment of left colon malignant emergencies. A new tool for operative risk evaluation

BACKGROUND/AIMS

The surgical treatment of left colon and rectal cancer emergencies is still controversial. In our opinion the choice is to be based on the general health status of each patient.

METHODOLOGY

We retrospectively analyzed our series of 57 patients who underwent immediate resection and anastomosis.

RESULTS

Factors significantly related to short-term results were chronic renal failure, heart disease, low albumin serum levels and colonic perforation. The presence of a diverting colostomy did not result in being a protective factor toward anastomotic dehiscence. We constructed a Colorectal Tumors Emergencies Score made of the identified four factors in which the score of each factor is the approximated odds ratio (chronic renal failure 7 points, low albumin serum levels 6 points, heart disease 5 points, colon perforation 4 points). Each patient was classified as Low Risk (CTES < 4), Moderate Risk (CTES 4-12) and High Risk (CTES > 12), mortality and morbidity being 4.3% and 21.7%, 24.0% and 60.0%, 88.9% and 88.9%, respectively.

CONCLUSIONS

High-risk patients may undergo a staged procedure. Moderate risk patient may be treated by immediate resection of the tumor, without anastomosis. Immediate resection and anastomosis may be reserved to low-risk patients.

Is endoscopic follow-up needed in pediatric patients who undergo surgery for GERD?

BACKGROUND

This study evaluated the role of endoscopy in the postoperative management of pediatric patients who undergo fundoplication for GERD.

METHODS

Medical records of 109 otherwise healthy children who underwent operation for GERD from 1979 to 1996 were reviewed. Patients with respiratory symptoms or esophageal stenosis were excluded. All patients underwent endoscopic surveillance with endoscopy being performed in the early (within 1 year) and late (between 1 and 2 years) postoperative periods. Specifically evaluated were the appearance of the wrap and evidence of esophagitis. The risk of a recurrence of esophagitis based on wrap appearance and the presence of clinical symptoms in patients with endoscopic evidence of esophagitis were also evaluated.

RESULTS

At early endoscopy 3 patients with an intact wrap and 8 with a defective wrap had esophagitis (not significant). At late endoscopy, 5 patients with an intact wrap and 17 with a defective wrap had esophagitis (p < 0.05).

CONCLUSIONS

An intact wrap does not prevent recurrence of GERD. Such an occurrence is even more likely when endoscopy demonstrates a defective wrap. For all patients who have undergone fundoplication, endoscopic evaluation at 1 to 2 years is recommended to detect esophagitis in the absence of symptoms so treatment can be initiated before symptoms occur.

The effect of mucin on bacterial translocation in I-407 fetal and Caco-2 adult enterocyte cultured cell lines

Although the intestinal mucosa forms a crucial barrier between the host and the environment, bacterial translocation (BT) occurs frequently in neonates and may be a source of sepsis. The intestinal mucous gel layer is thought to be a vital component of the gut barrier and is composed, in part, of a family of glycoproteins known as mucins. Our aim was to study the effects of mucin on BT in an enterocyte cell-culture model using a fetal (I-407) and an adult (Caco-2) intestinal cell line. I-407 and Caco-2 cells were grown to confluence on porous filters in a two-chamber Transwell system. The integrity of the monolayers was confirmed by transepithelial electrical resistance (TEER) and permeability using the macromolecule dextran blue. Cells were treated with mucin (40 mg/ml) prior to inoculation of 1 x 10(6) Escherichia coli C25. The magnitude of BT was determined quantitatively by culturing the samples from the basal chamber of the wells and was expressed as log 10 [Colony Forming Units (CFU)/ml]. Statistical analysis was performed by the Mann-Whitney U test with statistical significance at P < 0.05. Mucin inhibited BT across both fetal and adult cultured enterocyte monolayers; however, the inhibitory effect was less on the fetal cells compared to the adult cells. Dextran-blue studies showed that monolayers were intact throughout the experiments. Despite 98% inhibition of BT, mucin had a statistically significant effect on post-bacterial inoculation TEER in Caco-2 cells and no effect in I-407 cells. The ability of mucin, a mucous-barrier glycoprotein, to inhibit BT across immature intestinal enterocytes, as in the neonate, may be diminished compared to mature adult enterocytes.

Gastroesophageal reflux in neurologically impaired children: partial or total fundoplication?

BACKGROUND

It is difficult to give guidelines when approaching gastroesophageal disease in neurologically impaired children. Indication for surgery has been increasing over recent years, but there is no consensus on the surgical technique of choice. Nothing has been written specifically comparing the results of different procedures in these patients, so far.

STUDY DESIGN

We retrospectively compare the short- and long-term results of two different types of fundoplication in a series of children operated on for documented gastroesophageal reflux disease at our institution.

RESULTS

One group (group A) of 27 patients, operated on between 1977 and 1993, underwent Nissen fundoplication, the other (group B), formed of 20 patients all of whom were operated on between 1993 and 1995, underwent Thai fundoplication. We compared the results in terms of positive outcome (recovery) and negative outcome (minor and major complication), computing the relative odds of group A versus group B in terms of risk of complication, and we compared the mean operative time and the length of hospital stay by means of a student's t-test analysis.

CONCLUSIONS

Our results show that there is no statistical difference between the two procedures in terms of relative risk of complication and success rate. The duration of surgery and hospital stay were significantly shorter in group B. The Thal procedure can, therefore, be proposed as first choice in the management of these patients.

The use of cyanoacrylate tissue adhesive in high-risk intestinal anastomoses

The success of every intestinal surgical procedure primarily depends on correct technical execution of the intestinal sutures. Despite the continuing improvements in intestinal synthesis techniques and the introduction of mechanical staplers, the risk of anastomotic dehiscence remains a major concern. For high-risk anastomoses, defined as those performed under critical conditions, n-butyl-2-cyanoacrylate tissue adhesive allows for quick sealing of the two stumps and supports the physiological wound-healing process. Furthermore, no experimental or clinical studies have shown that this glue has any carcinogenic or mutagenic properties. Thus, we believe that n-butyl-2-cyanoacrylate will be extremely useful for intestinal anastomoses with a high risk of dehiscence.

[Wolfram syndrome. Peculiar urologic aspects]

The 6-year follow-up of a patient affected by Wolfram's syndrome, a rare disease characterized by diabetes insipidus (DI), diabetes mellitus (DM), optic atrophy (OA), neurosensory deafness (D), atony of the urinary tract and other abnormalities (DIDMOAD or Wolfram's syndrome), is described. Our patient has diabetes insipidus, diabetes mellitus, abnormal audiograms, without subjective evidence of hearing loss, and dilatation of the urinary tract. Diagnosis was suspected at the age of 8 years. Diabetes mellitus was the first manifestation and treatment with insulin was necessary. Desmopressin therapy decreased dramatically the daily urinary output. In view of the significant morbidity and mortality from renal failure associated with recurrent urinary infections, we have drawn special attention to the urological manifestations of the syndrome. During the follow-up, the patients underwent some investigations, such as renal ultrasound and echotomography and cystourethroscopy. Outstanding results of these studies are severe bilateral hydronephrosis with dilatated ureters and loss of renal tissue. The particular finding is the presence of posterior urethral valves with obstructed bladder. The anatomical outlet obstruction are variable and may be disastrous. There may be failure to thrive, sepsis, anemia be disanal failure. In such instances corrective surgery could improve bladder and ureteral functions.

Polymeric glues in intestinal surgery

Authors reports the results of an experimental study on the usefulness of n-butyl-2-cyanoacrylate in abdominal surgery. The research, performed on Wistar rats and Landrace pigs, is constituted by an early phase, to verify the tissue reaction to the n-butyl-2-cyano-acrylate and its adhesive properties, and a main phase, in which it was evaluated the efficacy of n-butyl-2-cyano-acrylate as the only support or as an adjunct to the usual methods in intestinal synthesis. histological and angiographic examination of the surgical specimens demonstrated the tissue autotoxicity and the good adhesive effect of the tissue glue. Because of these characteristic, authors propose its employment to reinforce intestinal sutures performed with the usual methods in high risk condition.