Maria Enrica Miscia

Background: The British Thoracic Society recommended tube thoracostomy plus intra-pleural fibrinolytics to treat empyema in children in 2005. However, numerous comparative studies have suggested Video-Assisted Thoracoscopic Surgery (VATS) as a first line of treatment for pediatric empyema due to its superior outcomes, including shorter length of hospital stay (LOS). This meta-analysis aimed to compare the following: (1) the LOS for VATS versus fibrinolytics to treat empyema in children; (2) secondary post-operative outcomes (fever, O₂ support, time taken for chest tube removal, analgesia, complications, failure, and abnormal chest X-ray at follow-up). Methods: The study was conducted according to PRISMA guidelines. A systematic search of PubMed, Cochrane, Web of Science, and Scopus was conducted according to PRISMA guidelines. Two independent investigators identified relevant studies, excluding case reports, opinion articles, and gray literature publications. A meta-analysis of randomized controlled trials (RCTs) was performed using RevMan 5.4, with data expressed as mean ± standard deviation (SD). Results: Of 1374 abstracts screened, 104 full-text articles were analyzed, and 6 RCTs (345 patients) were included in the meta-analysis. Patients undergoing VATS had significantly shorter LOS compared to those receiving fibrinolytics (9.1 ± 1.8 vs. 11.5 ± 2.5 days, p = 0.05). VATS patients also experienced shorter postoperative fever duration (4.2 ± 0.8 vs. 6.9 ± 4.6 days, p = 0.007) and earlier chest tube removal (5.0 ± 2.6 vs. 9.5 ± 3.3 days, p = 0.01). No significant differences were found between the two groups for other secondary outcomes. Conclusions: Children with empyema appear to benefit from VATS compared to tube thoracostomy plus fibrinolytics, with improved outcomes. Further RCTs are needed to corroborate these results.

Background: Anorectal malformations (ARMs) are a common pediatric surgical problem with an incidence of 1:1500 to 1:5000 live births. The phenotypical spectrum extends from anal stenosis to imperforate anus with or without anal fistula to persistent cloaca. They can manifest as either non-syndromic or syndromic conditions. Various environmental and genetic risk factors have been elucidated. The widespread use of genetic screening tests for the investigation of developmental disorders increased the recognition of copy number variants (CNVs) of the 1q21.1 region. Duplications have also been associated with a multitude of congenital anomalies, such as heart disease, short stature, scoliosis, urogenital, and ARMs, and they have also been found in healthy individuals. The aim of this manuscript is to contribute to the definition of the phenotype associated with 1q21.1 duplications. Case presentation: The present case describes a male, referred to us for an ARM, in whom array—comparative genomic hybridization (array-CGH) identified 1q21.1 duplication inherited from his healthy mother. No other genetic test was performed on the patient. Conclusions: We propose considering genetic evaluation and analysis in patients with only one congenital malformation in order to eventually make an early diagnosis and a better quality of treatments.

Background: We aimed to compare among patients with high-type anorectal malformations (ARM): (i) short- and long-term outcomes of laparoscopic-assisted anorectoplasty (LAARP) compared to classic posterior sagittal anorectoplasty (PSARP) and (ii) the results of single-stage versus staged PSARP. Methods: Using a defined search strategy, two independent investigators systematically reviewed the English literature. PRISMA guidelines were followed, and meta-analysis was performed using RevMan5.3. Results: Of 567 abstracts screened, 7 papers have been included (254 pts; 121 PSARP, 133 LAARP) in the first systematic review and meta-analysis. The length of hospitalization was shortened in LAARP versus PSARP (10.9 versus 14.4 days; p < 0.0001). PSARP and LAARP were comparable in terms of early postoperative complications (28.9% versus 24.7%; p = ns) and rectal prolapse (21.6% versus 17.5%; p = ns). At long-term follow-up, the presence of voluntary bowel movements (74.0% versus 83.5%; p = ns) and the incidence of soiling (45.5% versus 47.6%; p = ns) were similar in both PSARP and LAARP. Six papers (297 pts) were included in the second systematic review, with three comparative studies included in the meta-analysis (247 pts; 117 one-stage, 130 staged procedures). No significant difference in terms of presence of voluntary bowel movements after single-stage versus staged procedures (72.6% versus 67.3%; p = ns) has been detected. Conclusions: LAARP seems to be a safe and effective procedure, showing short- and long-term outcomes similar to PSARP. One-stage PSARP could be a safe alternative to the classic three-stage procedure, even for those infants with high-type ARM. Further and larger comparative studies would be needed to corroborate these partial existing data.

Management of pediatric Primary Spontaneous Pneumothorax (PSP) is controversial and based on guidelines on adults. Therapeutic strategies include: observation, needle aspiration, chest drain, or surgery. We aimed to assess: i) differences in the management of PSP in pediatric vs. adult departments; ii) risk of recurrence associated to each therapeutic choice; iii) management of “large” pneumothorax (i.e. >3cm at the apex on chest X-Ray); iv) role of CT scan in addressing the treatment. We reviewed all PSP treated at Pediatric Surgery Unit (PSU) and Thoracic Surgery Unit for adults (TSU) in a 10-year period (2011 to 2020). We included a total of 42 PSP: 30/42 1st episodes and 12/42 recurrences. Among the 30/42 1st episodes, 15/30 were managed in the PSU and 15/30 in the TSU. Observation was significantly most common among PSU patients (9/15, 60%) vs. TSU cases (1/15, 6.7%; p=0.005]. Chest drain placement was reduced in PSU (3/15, 20%) vs. TSU (12/15, 80%; p=0.002). Observational was associated with a reduced risk of recurrence (0/10, 0%) compared to chest drain (7/15, 46.7%; p=0.01). Management of 20/42 “large” pneumothorax was: 4/20 (20%) observation, 10/20 (50%) chest drain, 2/20 (10%) needle aspiration, 4/20 (20%) surgery. Twentythree/ 29 PSP (79.3%) underwent CT-scan after the first episode. Bullae were detected in 17/23 patients and 5/17 (29.4%) had seven episodes of recurrence. PSP patients treated by PSU were more likely to receive clinical observation. Those managed by TSU were mostly treated by chest drain. Observation seems an effective choice for clinically stable PSP, with low risk of recurrence at a mid-term follow-up. CT-scan seems not to detect those patients at higher risk of recurrence.

Circulating Endothelial Cells (CEC) and Circulating Extracellular Vesicles (cEVs) are biological markers of endothelial activity/disfunction and may play a pivotal role in the evolution of IH. Our aims were to detect variations in CEC and cEVs concentration: 1. in IH versus healthy controls; 2. in IH before and after propranolol administration. Twenty-two children (15 cases; 7 controls) from our Department underwent peripheral blood sampling to study CECs, EPCs and EVs via cytofluorimetry. Statistical analyses were performed using XLSTAT ver. 2014.5.03 and GraphPad Prism ver. 8.0. Data were expressed as mean ± standard deviation, median, 5-95th percentile. The number of CEC and HSC was higher among cases than controls, even if not statistically significant. The number of CEC decreased with the evolution of the hemangioma; number of HSC decreased proportionally with the age of the patienst. Number of EVs tended to increase when the CECs decrease and vice-versa in the group of cases but not among controls. Number of CEC and HSC was significantly reduced after oral propranolol administration (p: <0,0001). In conclusion CECs may represent a marker of progression of disease. Propranolol seems to affect the number of CECs and HSCs.

Article: Subumbilical versus transumbilical laparoscopic assisted appendectomy in children: a caregivers-centered cosmetic satisfaction evaluation - Chirurgia 2021 June;34(3):105-9 - Minerva Medica - Journals

Hydrosalpinx in pre-pubertal children and non-sexually active adolescents is a rare finding with several etiology and negative impact on future female fertility. The therapeutic approach in these specific populations is debated and it must consider its etiology and adult guidelines focused on fertility issues, which suggest laparoscopic salpingectomy. We described two adolescent cases (15 years asymptomatic and 13 years with abdominal pain) presenting a monolateral hydrosalpinx secondary to surgery for Hirschsprung’s disease and complicated appendicitis, respectively. Both patients underwent to uncomplicated robotic-assisted salpingectomy, with uneventful follow-up and preserved ovarian function. Robotic-assisted salpingectomy for hydrosalpinx secondary to previous surgical conditions is a safe and careful approach for adolescents in order to preserve ovarian vascularization, function and future fertility.

Introduction Esophageal atresia (EA) is associated with duodenal atresia (DA) in 3 to 6% of cases. The management of this association is controversial and literature is scarce on the topic. Materials and Methods We aimed to (1) review the patients with EA + DA treated at our institution and (2) systematically review the English literature, including case series of three or more patients. Results Cohort study: Five of seventy-four patients with EA had an associated DA (6.8%). Four of five cases (80%) underwent primary repair of both atresia, one of them with gastrostomy placement (25%). One of five cases (20%) had a delayed diagnosis of DA. No mortality has occurred. Systematic Review: Six of six-hundred forty-five abstract screened were included (78 patients). Twenty-four of sixty-eight (35.3%) underwent primary correction of EA + DA, and 36/68 (52.9%) underwent staged correction. Nine of thirty-six (25%) had a missed diagnosis of DA. Thirty-six of sixty-eight underwent gastrostomy placement. Complications were observed in 14/36 patients (38.9 ± 8.2%). Overall mortality reported was 41.0 ± 30.1% (32/78 patients), in particular its incidence was 41.7 ± 27.0% after a primary treatment and 37.0 ± 44.1% following a staged approach. Conclusion The management of associated EA and DA remains controversial. It seems that the staged or primary correction does not affect the mortality. Surgeons should not overlook DA when correcting an EA.

Giant mesenteric lipoblastoma is a rare benign tumor arising from the adipocytes. It can mimic malignant tumors, and its diagnosis is difficult before surgery. Imaging studies could lead the diagnosis but not confirm it. Those tumors arising in the abdomen are usually larger and can cause symptoms of compression. Surgical excision is the treatment of choice, and a long-term follow-up is necessary to detect local recurrences. Only a few cases of lipoblastomas arising from the mesentery are reported in literature. We present a case of a rare giant lipoblastoma arising from the mesentery of a 6-year-old girl, with a history of postprandial abdominal pain.