Salvatore Fabio Chiarenza

Background and Clinical Significance: Acute appendicitis following blunt abdominal trauma is a rare and historically debated clinical entity. We present a century-spanning descriptive review of 106 cases of post-traumatic appendicitis, embedded with an illustrative pediatric case initially managed conservatively. Methods: A comprehensive literature review was conducted following PRISMA guidelines across PubMed/MEDLINE, Web of Science, and Google Scholar, encompassing a 100-year period (1925–2025). Clinical variables, trauma mechanisms, and outcomes were extracted and statistically analyzed by age cohort (Pediatric ≤ 18 vs. Adult > 18) and historical medical era. Results: A total of 106 cases were analyzed. High-energy trauma predominated in adults compared to the pediatric cohort (48.8% vs. 18.5%, p = 0.001). The overall complication rate was exceptionally high (66.0%), with no significant difference between pediatric and adult cohorts (61.5% vs. 73.2%, p = 0.293). An epoch-based analysis revealed a significant drop in perforation rates from the historical era (1925–1980) to the modern era (2001–2025) (51.7% to 27.0%, p = 0.033) due to improved diagnostic timelines. Crucially, purely mechanical injuries such as complete appendiceal auto-amputation remained a constant signature of blunt trauma across the century (11.5% overall rate). Conclusions: Our synthesis of historical cases suggests that post-traumatic appendicitis might be a relevant clinical entity where trauma mechanics appear to play a significant role in injury severity, irrespective of patient age. While conservative management could be feasible and safe in the acute setting of uncomplicated cases, we hypothesize that the initial kinetic impact might cause subtle structural changes or alter local appendiceal dynamics, potentially predisposing the organ to recurrent inflammation, warranting close follow-up or elective surgery.

Introduction: Congenital duodenal atresia (DA) (Type I) with a fenestrated web can be characterized by a late presentation with a delayed diagnosis. It is even rarer and usually associated with proximal duodenomegaly. Conventional management involves web resection and duodeno–duodeno anastomosis with or without duodenoplasty. We describe our mininvasive surgical strategy and management, detailing the aspects of laparoscopic techniques. Material and Methods: We retrospectively reviewed the medical records of five patients affected by fenestrated duodenal web (DA) with a delayed onset of symptoms and diagnosis who were managed in our Department over a period of 10 years (2013–2023). We analyzed the age of patients at diagnosis, clinical signs and symptoms, associated congenital anomalies, radiological and intraoperative findings, surgical treatment, and outcomes. Diagnostic examinations included ultrasound (US), Upper-Gastrointestinal Study (UGI), and Esophagogastroduodenoscopy (EGDS). Results: Three boys and two girls, median age of 5.5 months (range 3–11 months), were included in this study. Three underwent previous surgery for long-gap esophageal atresia (EA), two of Type A, and one of Type C, requiring a gastrostomy immediately after birth (delayed esophageal repair for prematurity in Type C) and subsequent delayed primary anastomosis. Major associated anomalies were EA (3), anterior ectopic anus (1), cloaca (1), and Type IV laryngeal web (1). An antenatal diagnostic suspicion of duodenal atresia (obstruction) on ultrasound was described in two patients. UGI suggested a fenestrated duodenal web, visualized at ultrasound in two patients. Duodenal dilation was associated in two cases. The symptoms were feeding difficulties, nonbilious vomiting, upper abdominal distension, and poor growth. All presented with a pre-ampullary obstruction. Endoscopic confirmation was only possible in one patient. The older patient underwent an endoscopic resection of a duodenal web. In the other four, we performed a laparoscopic longitudinal antimesenteric duodenal incision, web resection (excision), and transverse suture (closure was performed) without duodenoplasty. Intraduodenal Indocyanine Green (ICG) visualization (under near-infrared light) was used in the last two cases. No postoperative complications were recorded, with a mean hospital stay of 8 days. A contrast study performed at 4 weeks demonstrated an improved proximal duodenal profile; patients tolerated a full diet and remained symptom-free. Conclusions: According to our experience with minimally invasive techniques, laparoscopy and endoscopy are effective and safe, supporting web resection for the management of a duodenal web without tapering of the proximal duodenum. They require advanced technical skills. Intraduodenal-ICG injection during laparoscopic treatment of Type 1 DA allows localization of the duodenal web, confirmation of bowel patency (bowel canalization) and the tightness of suture.

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

Background: Congenital h-type tracheoesophageal fistula (H-TEF) without esophageal atresia (EA) represents about 4% of congenital esophageal anomalies. The diagnosis is challenging, and surgery is considered curative. The aim was to report a national survey on the diagnosis, management, and outcome of patients with congenital H-TEF. Methods: Following approval of the Italian Society of Pediatric Surgery, a survey was sent to all Pediatric Surgery Units to retrospectively collect H-TEF treated in the period 2010–2022. Descriptive analysis was performed, and results are given as prevalence, mean ± standard deviation (SD), or median and interquartile range (IQR). Results: The survey was sent to 65 units. Seventeen responded with one or more cases; 78 patients were diagnosed with H-TEF during the study period. Associated malformations were present in 43%, mostly cardiac (31%). The most frequent symptoms were cough (36%), bronchopneumonia (24%), and dysphagia (19%). H-TEF was detected by tracheobronchoscopy (90%), and/or upper GI (58%), and/or esophagoscopy (32%). The median age at diagnosis was 23 days (1 day–18 years). The most common approach was cervicotomy (76%), followed by thoracoscopy (14%) and thoracotomy (9%). The fistula underwent ligation and section of the fistula in 90% of the patients and clip closure and section in 9%. In one patient, the fistula was cauterized endoscopically. H-TEF preoperative cannulation was performed in 68% of cases, and a drain was placed in 26%. One month after surgery, 13% of the patients had mild persisting symptoms, mainly hypophonia. Recurrence occurred in 5%, and a second recurrence occurred in 1%. Conclusions: H-TEF prevalence was six cases/year, consistent with the expected rate of five cases/year in our country. The diagnosis was challenging, sometimes delayed, and, in most patients, required multiple examinations. Fistula ligation and section through cervicotomy were the most frequent treatment. Long-term outcomes are good, and recurrence is a rare event.

Introduction: Gastric volvulus (GV) is a rare and life-threatening condition if not promptly diagnosed and treated. Extreme rotation can cause obstruction cutting off blood supply to stomach and distal organs, leading to ischemia and necrosis. It is a clinically significant cause of acute/recurrent abdominal pain and chronic vomiting in children. GV can be classified into the following: primary, secondary, organoaxial, mesenteroaxial, or combined, acute, or chronic. Materials and Methods: Six neonates (5 males-1 female) were admitted to our department for recurrent postprandial vomiting associated with paleness, hyporeactivity, transitory abdominal distension, failure to thrive, and respiratory infections (only-1). Median age: 6 months (range 2–9 months). Patients metabolic and neurological evaluations were normal. A barium-swallow-study (upper gastrointestinal [UGI]) allowed definitive diagnosis. Results: UGI and esophagogastroduodenoscopy (EGDS) showed a gastric abnormal dilatation (gastric fundus), hiatal hernia (HH) in 5 patients, a large/small curvature discrepancy in 3 patients. Four were chronic-organoaxial-GV, 2 chronic-mesenteroaxial-GV. All underwent Laparoscopic-Hill-Snow-gastropexy (LHSG) with HH correction. No intraoperative/postoperative complications were recorded. Refeeding started in first postoperative day. Average hospital stay: 6-days. At long-term follow-up, all patients were symptoms free (able to vomit/burp); 2 referred occasionally epigastric pain sometimes with vomit. At 10–12 years follow-up UGI and EGDS confirmed correct gastric position revealing gastroduedenitis. Discussion: GV is a rare clinical entity in children considering etiology and management with an important morbidity and mortality rate. Its diagnosis could be missed simply. Vomiting or HH on imaging studies should suggest GV regardless patient's stable appearance. Conclusions: Chronic GV can manifest with atypical chest, abdominal, and gastrointestinal symptoms. Early diagnosis and treatment reduce the risk of developing acute form. LHSG is a long-term effective and safe solution with a very low complication rate, and no symptoms correlated to Nissen procedure.

Intramural duodenal hematoma (IDH) is a rare complication after small-bowel endoscopic biopsy; it occurs mainly in children with impaired coagulation [1] [2] [3] [4] [5]. We report the case of a 13-year-old girl with no relevant medical history who was complaining of abdominal tenderness and failure to thrive and underwent a diagnostic esophagogastroduodenoscopy (EGD) with duodenal biopsies ([Fig. 1]). After 24 hours, she presented with nonbloody, nonbilious vomiting, and diffuse and intense abdominal pain. Abdominal ultrasound and a contrast-enhanced computed tomography scan revealed an asymmetric thickening of the duodenal wall measuring 80 × 50 mm, suggestive of an IDH ([Fig. 2]). Laboratory testing showed that she had previously unknown platelet dysfunction. Only at this time did the family reveal details of an episode of hemarthrosis after minor trauma that they had previously omitted to mention. The patient was treated with total parenteral nutrition, systemic antibiotics, proton pump inhibitors, and nasogastric tube suction. On day 11, a repeat EGD showed a large IDH bulging into the duodenum ([Fig. 3 a]; [Video 1]). An unsuccessful attempt to pass the obstruction with an 8-mm instrument over a guidewire ([Fig. 3 b]) was made. A 5-mm endoscope (SN143POK241; Fujifilm) was however successfully passed through the narrowed lumen at the stenosis, which allowed us to check that the ampulla of Vater was not compressed ([Fig. 3 c]). After this maneuver, the duodenal lumen appeared patent, with an improvement in the degree of obstruction. Video 1 Endoscopic and computed tomography views of a huge intramural duodenal hematoma in a 13-year-old girl with undiagnosed platelet dysfunction after diagnostic duodenal biopsies were previously taken during esophagogastroduodenoscopy. On the 15th postoperative day, the nasogastric tube was removed. The day after its removal, the patient tolerated oral feeding, which was then gradually increased. An ultrasound scan on day 25 showed near-complete resolution of the hematoma and the patient was discharged. Full resorption of the IDH was confirmed on follow-up ultrasound 1 month later. IDH is a very rare complication after endoscopic biopsies, especially in the pediatric population. Its treatment is still debated, but conservative management should be considered the first choice. Furthermore, an accurate anamnesis is fundamental in the diagnostic assessment in order to prevent serious complications, such as the one described here. Endoscopy_UCTN_Code_TTT_1AO_2AB Article published online: 25 May 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. Scalp-IHs are usually focal lesions that can be both disfiguring and may lead to complications such as ulceration and bleeding. We describe a case of a 30-months old female who presented a large scalp-IH at birth that rapidly grew in the first year of life. Topical and systemic treatments (with timolol ointment and oral propranolol, respectively) were not effective in reducing dimensions of the hemangioma. After vascular imaging study, the patient underwent surgical resection of the IH and primary closure with excellent cosmetic outcome. When medical therapy is ineffective or cosmetic and functional integrity is threatened, early surgery allows to completely removing large scalp-IHs, with good cosmetic results.

Minimally invasive surgery (MIS) in pediatric population is becoming more and more popular among pediatric urologists and now it can be considered the best treatment for nephroureterectomy that is one of the most frequent urological procedures. The main indications to MIS ureteronephrectomy in children are congenital or acquired benign conditions such as nonfunctional and/or damaging kidney, renal dysplasia, and destroyed kidneys due to obstructive or refluxing uropathy. Since ever in open urological surgery, the lateral retroperitoneal approach represents the typical way to approach this kind of surgery. Although different surgical approaches can be chosen (i.e., posterior retroperitoneal, lateral retroperitoneal, laparoscopic transperitoneal, and robotic approach), the lateral retroperitoneal approach represents the typical way to perform this kind of surgery, also with minimally invasive techniques. In this article, we illustrate the technique of retroperitoneoscopic nephroureterectomy in infants and children, reporting our experience with this technique in the past 20 years.