Tommaso Gargano

Background: Aorto-esophageal fistula (AEF) is a rare but life-threatening condition in children following foreign body (FB) ingestion, with button batteries (BB) being the most dangerous. These batteries involve severe tissue necrosis due to chemical and electrical reactions, often leading to fistula formation and catastrophic hemorrhage. Appropriate treatment for AEF is still undefined. Method: This report presents a novel case of AEF closure using a covered stent in a 4-year-old boy, complemented by a narrative review of 36 reported pediatric AEF cases from 1988 to 2024. Results: The review revealed that BB ingestion accounted for 67% of AEF cases, with a high mortality rate of 43%, underscoring the critical nature of this condition. Early symptoms are often nonspecific, leading to delayed diagnoses, which worsen outcomes. Computed tomography (CT) is the key imaging modality for detecting vascular complications such as AEF, while X-ray may help identify the foreign body, but is often insufficient to assess associated injuries. While surgical repair remains the mainstay of treatment, minimally invasive techniques, such as endovascular approaches, are emerging as viable options. Conclusions: This study highlights the need for heightened public awareness, safer battery designs, and prompt, multidisciplinary interventions to improve patient outcomes. Future research should focus on refining diagnostic protocols, evaluating innovative management strategies, and establishing comprehensive registries to inform evidence-based guidelines and optimize care.

Background: Minimally invasive surgery (MIS) is increasingly adopted in pediatric surgical practice, yet it demands specific technical skills that require structured training. Simulation-based education offers a safe and effective environment for skill acquisition, especially in complex procedures such as thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA-TEF). Objective: This study aimed to evaluate the effectiveness of a 3D-printed simulator for training pediatric surgeons in thoracoscopic EA-TEF repair, assessing improvements in operative time and technical performance. Methods: A high-fidelity, 3D-printed simulator replicating neonatal thoracic anatomy was developed. Six pediatric surgeons at different training levels performed eight simulation sessions, including fistula ligation and esophageal anastomosis. Operative time and technical skill were assessed using the Stanford Microsurgery and Resident Training (SMaRT) Scale. Results: All participants showed significant improvements. The average operative time decreased from 115.6 ± 3.51 to 90 ± 6.55 min for junior trainees and from 100.5 ± 3.55 to 77.5 ± 4.94 min for senior trainees. The mean SMaRT score increased from 23.8 ± 3.18 to 38.3 ± 3.93. These results demonstrate a clear learning curve and enhanced technical performance after repeated sessions. Conclusions: Such 3D-printed simulation models represent an effective tool for pediatric MIS training. Even within a short time frame, repeated practice significantly improves surgical proficiency, supporting their integration into pediatric surgical curricula as an ethical, safe, and efficient educational strategy.

Background: Indocyanine green (ICG) fluorescence imaging has revolutionized pediatric surgery by enhancing precision, safety, and outcomes across various specialties. In recent years, its use has spread through the framework of pediatric surgery, where its ability to illuminate anatomical structures and pathological conditions has improved surgical outcomes. Methods: We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was performed using the term “Indocyanine green” in all fields, including papers about pediatric patients (aged 0–18 years) published between January 2014 and July 2024. Results: This review systematically explores ICG applications, dosing regimens, timing of administration, and integration into modern surgical technologies, including robotics and minimally invasive platforms. ICG resulted in an excellent safety profile and enables the real-time visualization of anatomical structures and pathological conditions, proving invaluable in pediatric cases characterized by smaller anatomical dimensions and congenital anomalies. Conclusions: This review highlights ICG fluorescence imaging as an indispensable tool in pediatric surgery, offering transformative potential for improving surgical outcomes and patient safety. Despite its advantages, it is necessary to standardize dosing and timing protocols to maximize its utility. The aim of this review is to explore the various applications of ICG in pediatric surgery, report the dosage and administration times across different surgical fields, and establish best practices to guide its future use.

Background: Gastroesophageal reflux disease (GERD) is a prevalent and severe condition in neurologically impaired (NI) children, often requiring surgical intervention. This study evaluates the outcomes of two surgical techniques, fundoplication and total esophagogastric dissociation (EGD), in managing GERD in this vulnerable population. Methods: We conducted a retrospective analysis of 56 NI children who underwent surgery for GERD at our institution from 2012 to 2023. Outcomes assessed included post-operative weight gain, pneumonia rates, hospitalization duration, and complications. Results: Of the cohort, 39 patients underwent fundoplication and 17 underwent EGD. Both groups experienced significant weight gain post-operatively, with comparable rates between procedures. Fundoplication was associated with shorter hospitalization (16 ± 10 days vs. 35 ± 16 days, p < 0.001) and earlier resumption of enteral feeding (5.5 ± 2 days vs. 10.2 ± 3 days). EGD significantly reduced pneumonia rates (70.59% to 17.65%, p = 0.006) compared to fundoplication (58.97% to 41.03%, p = 0.174). Early complication rates were higher in the EGD group (41% vs. 23%), but long-term GERD-related hospitalizations were fewer (0.8 ± 1/year vs. 3 ± 2/year, p = 0.003). Conclusions: Fundoplication offers shorter recovery times and lower early complication rates, making it suitable for many patients. However, EGD may be preferable for those with severe, refractory GERD, given its superior long-term outcomes, particularly in reducing pneumonia and hospitalizations. Prospective studies are needed to confirm these findings and refine surgical indications in NI children.

Background: In pediatric surgery, a comprehensive knowledge of the child’s anatomy is crucial to optimize surgical outcomes and minimize complications. Recent advancements in medical imaging and technology have introduced innovative tools that enhance surgical planning and decision-making. Methods: This study explores the integration of mixed reality technology, specifically the HoloLens 2 headset, for visualization and interaction with three-dimensional (3D) anatomical reconstructions obtained from computed tomography (CT) scans. Our prospective observational study, conducted at IRCCS (Scientific Hospitalization and Care Institute) Sant’Orsola-Malpighi University Hospital in Bologna, engaged ten pediatric surgeons, who assessed three types of anatomical malformations (splenic cysts, pulmonary cystic adenomatoid malformations, and pyelo-ureteral junction stenosis) and planned surgeries using both traditional 2D CT scans and 3D visualizations via HoloLens 2, followed by completing a questionnaire to evaluate the utility of each of these imaging techniques in surgical planning. Results: The statistical analysis revealed that the 3D visualizations significantly outperformed the 2D CT scans in clarity and utility (p < 0.05). The results indicated significant improvements in anatomy understanding and surgical precision. The immersive experience provided by HoloLens 2 enabled surgeons to better identify critical landmarks, understand spatial relationships, and prevent surgical challenges. Furthermore, this technology facilitated collaborative decision-making and streamlined surgical workflows. Conclusions: Despite some challenges in ease of use, HoloLens 2 showed promising results in reducing the learning curve for complex procedures. This study underscores the transformative potential of mixed reality technology in pediatric surgery, advocating for further research and development to integrate these advancements into routine clinical practice.

Purpose: Acute appendicitis (AA), classified as non-complicated acute appendicitis (NCAA) and complicated acute appendicitis (CAA), is the most common cause of abdominal pain in children requiring surgical treatment. If the first-line treatment for NCAA is to be debated between conservative management and surgery, authors find a consensus in choosing surgery as the first step for CAA in children. In the case of patients with CAA undergoing surgery, a broad-spectrum antibiotic therapy should be administered to reduce the risk of post-operative complications (POC). The rise in antibiotic resistance requires a review of recent data regarding bacterial species involved in AA. The primary aim of our study was to investigate the clinical effectiveness of different antibiotic protocols in patients undergoing surgery for CAA. The secondary aim was to verify the antibiotic’s in vitro effectiveness based on cultural examinations. Methods: A retrospective and prospective study was conducted on all patients operated on at our pediatric surgery department for CAA from January 2017 to January 2023. The following data were collected: age at surgery, sex, surgical technique, duration of the procedure, antibiotic therapy, duration of the hospital stay, cultural examination of peritoneal effusion, and POC. Results: We divided the patients enrolled (n = 182) into three groups of antibiotic protocols; only one group resulted in a statistically significant lower rate of POC. Different pathogens were isolated (Enterobacteriaceae, non-fermentative Gram-negative bacilli, anaerobes, Gram-positive cocci), and the in vitro rate of antimicrobial sensitivity varied from 40% to 94% in the three groups of patients. Conclusions: Based on cultural examinations, our study showed a high rate of inadequacy regarding the therapy with amoxicillin + clavulanic acid despite a low rate of complications. Radical surgery seems to be the best way to reduce complications in children with CAA.

Introduction: Omphalocele (OM) is a congenital defect of the abdominal wall. The main goal of the surgical management is the survival of the neonate. However, the residual scar following the surgery can be extremely burdensome and negatively impact the quality of life (QoL) of these patients. The aim of this study is to assess the cosmetic results of the surgical treatment, the level of satisfaction of patients and surgeons, and the influence of the scar on the QoL of the patient. Materials and methods: We conducted an observational retrospective cross-sectional study collecting all data regarding patients born with OM, operated at our Centre between 1998 and 2021. The cosmetic results of the surgical repair were evaluated using the validated Patient and Observer Scar Assessment Scale (POSAS). The assessment of the quality of life determined by the presence of the scar was conducted using PedQL 4.0. At last, the patients were visited by two paediatric surgeons and a medical student, which then scored the cosmetic result of the scar. Statistical analysis was conducted with Spearman linear correlation and Mann–Whitney test. A P-value below 0.05 was considered statistically significant. Results: In our study, we included a total of 19 patients, with a mean of 12 years of age at the time of the evaluation. The parameters with the major influence on the patient’s general opinion of the scar were stiffness, thickness, and irregularity. We discovered significant differences in median values of all scores between the giant OM group and the nongiant OM group, in favour of the latter. Finally, we found a low grade of concordance between PedsQL filled by parents and patients. Conclusion: The POSAS scale is a valid, feasible, and reliable tool for the assessment of the aesthetic outcome of surgical procedures. The original size of the defect is the most important factor acting on the result. However, it is crucial that any decision on plastic surgery to improve the looks of the scar must be postponed to the adult age of the patient. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Platelet-Rich Plasma (PRP) therapy has become a promising treatment option in pediatric surgery, offering a novel approach to tissue repair and regeneration. Obtained from the patient’s own blood or umbilical cord blood (CB), PRP is a concentrated form of plasma enriched with platelets, growth factors, and cytokines essential for stimulating tissue healing. This systematic review explores the applications of PRP therapy in pediatric surgical procedures, focusing on its role in promoting wound healing, reducing postoperative complications, and enhancing patient outcomes. A systematic literature overview was conducted in accordance with PRISMA guidelines, encompassing studies published between 2004 and 2024. The research has identified different fields of application for PRP therapy in pediatric surgery, including treatment of pilonidal sinus and hypospadias repair. Key findings from clinical studies and randomized controlled trials are summarized, highlighting the efficacy of PRP therapy in accelerating wound healing, reducing pain, and improving patient recovery. Despite promising results, challenges and controversies surrounding PRP therapy persist, including variability in preparation protocols and optimal dosing regimens. The safety of PRP therapy in pediatric patients is also discussed, emphasizing its autologous nature and minimal risk of adverse reactions. In summary, this review highlights the role of PRP therapy as a safe and effective therapeutic approach in pediatric surgery, while further research to standardize protocols and elucidate optimal treatment strategies are still necessary.

Postoperative management of esophagocutaneous fistulas in pediatric patients is challenging, often resulting in prolonged hospitalization and increased morbidity. Platelet-rich plasma (PRP) has emerged as a promising adjunctive treatment for such complications. We present the case of a 7-month-old infant who developed an esophago-cutaneous fistula following esophagocoloplasty for esophageal atresia type A. Despite initial conservative management, the fistula persisted, prompting the application of PRP gel derived from umbilical cord blood. After four applications of PRP, complete closure of the fistula was achieved, leading to both functional and aesthetic results. This case highlights the potential of PRP in managing refractory postoperative esophageal fistulas in pediatric patients and underscores the need for further research to optimize treatment protocols and validate its efficacy for this sort of complications

Background: Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI’s management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children. Materials and methods: The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application. Results: An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use. Conclusion: We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.