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Background Inguinal hernia containing the uterus in pediatric patients with normal karyotype and phenotype is an extremely rare entity, and no consensus is available concerning diagnosis, surgical management and follow-up. Methods A systematic review according the Synthesis without Meta-analysis (SwIM) protocol was conducted. Studies including pediatric female patients with inguinal hernia containing the uterus were searched. Keywords and mesh term searches were conducted (Medline, Scopus and Web of Science). We additionally reviewed our Center's clinical records, finding one patient with inguinal uterus hernia that was included in the statistical analysis. Results 36 articles and 73 patients were considered for this analysis. The median gestational age at birth was 36 weeks. The inguinal mass was first noticed at the median age of 1.5 months (0-18 months), on the left side in 61% (on the right in 16 39%). Sixty percent of patients had no associated symptoms nor signs; 37.5% showed symptoms and signs of an incarcerated hernia. Median age at surgery was 2 months (1-72 months). In all patients, one or both adnexa herniated with the uterus. An open approach was more frequently used (56.4%). Contralateral duct exploration and ligation was performed in 7 patients (24.1%). No post-operative complications nor recurrences have been described. Conclusions Data obtained do not allow us to draw univocal conclusions on whether which is the best management in these patients: it is still unclear if an elective approach in an asymptomatic patient may bear long term consequences on reproductive functions. No surgical technique proved to be superior to others, but both the open and laparoscopic approaches seem to be effective without postoperative complications nor recurrences.

Background A unique Case of metachronous contralateral cystadenoma diagnosed 2 years after a juvenile granulosa cell tumor (JGCT) of the ovary is reported. Case One year after a left ovariectomy for JGCT, a 7 year-old girl was found to have, during her standard ultrasound follow-up, a 18-mm cyst in the right ovary, which was initially considered to be a follicular cyst. Six months later, the mass appeared to be increased and characterized by multivacuolar features, and inhibin A was mildly elevated. A laparoscopic-assisted cystectomy was performed, sparing healthy ovarian tissue around. The pathology report showed a benign mucinous cystadenoma.

The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic.The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19.Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate.A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test.Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective.We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.

Ectropion of anal mucosa (AME) is a possible complication following anorectal surgery and it is often cause of symptoms such as soiling, pain and bleeding affecting the patients' quality of life. Two-flaps anoplasty has been previously described for the correction of AME. We herein report a case of an adult patient who underwent a successful double V/Y-flaps for mucosal ectropion as consequence of repair of anorectal malformation (ARM).A 25 year-old woman with history of ARM presented with an extensive AME causing bleeding, pain, soiling, and dyspareunia. This condition prevented her from an effective rectal nursing and a satisfactory social life.The patient underwent the resection of ectopic mucosa and the creation of two V-shaped skin flaps to cover the skin gap. A minor dehiscence of one of the flaps was treated conservatively. At two years follow up the patient is symptoms free, has a good quality of life and can perform an effective bowel management.AME is a possible complication after anorectal surgery for ARM and the multiple V-Y plasty is a viable procedure for its treatment. A multidisciplinary approach in these cases is recommended.Level of Evidence V. Keywords: Anorectal malformation, Anoplasty, V-Y flaps, Mucosal ectropion

Biological scaffolds derived from decellularized tissues are being investigated as a promising approach to repair volumetric muscle losses (VML). Indeed, extracellular matrix (ECM) from decellularized tissues is highly biocompatible and mimics the original tissue. However, the development of fibrosis and the muscle stiffness still represents a major problem. Intercellular signals mediating tissue repair are conveyed via extracellular vesicles (EVs), biologically active nanoparticles secreted by the cells. This work aimed at using muscle ECM and human EVs derived from Wharton Jelly mesenchymal stromal cells (MSC EVs) to boost tissue regeneration in a VML murine model. Mice transplanted with muscle ECM and treated with PBS or MSC EVs were analyzed after 7 and 30 days. Flow cytometry, tissue analysis, qRT-PCR and physiology test were performed. We demonstrated that angiogenesis and myogenesis were enhanced while fibrosis was reduced after EV treatment. Moreover, the inflammation was directed toward tissue repair. M2-like, pro-regenerative macrophages were significantly increased in the MSC EVs treated group compared to control. Strikingly, the histological improvements were associated with enhanced functional recovery. These results suggest that human MSC EVs can be a naturally-derived boost able to ameliorate the efficacy of tissue-specific ECM in muscle regeneration up to the restored tissue function.

The use of the Da Vinci Xi system is gaining popularity among all surgical disciplines. A splenectomy is a treatment option for patients with hematological disorders and splenic lesions. The laparoscopic approach is nowadays the standard of care. Despite the initial controversy, recently it has been demonstrated the superiority of robotic splenectomy performed in "difficult" cases. We report, to our knowledge, the first case of robot-assisted splenectomy following embolization of the splenic artery in a 15-year-old patient with chronic immune thrombocytopenia, worsened by a severe cerebral sinus thrombosis, while being treated with eltrombopag and mycophenolate. Due to the need for a rapid rise in platelet counts and failure of several medical treatments, splenectomy was advocated. To raise the platelet count pre-operatively and minimize intraoperative bleeding, the embolization of the spleen artery was performed before the planned splenectomy. The intervention was carried on without any complication and at 1 year follow up the patient is in good clinical condition and has improved his neurological condition. We propose a robotic splenectomy following embolization of the splenic artery as a feasible and safe procedure. The advantages of the Da Vinci Xi system are highlighted especially in complex cases, requiring maximum precision.

Gas embolism is a possible complication during head and neck surgery and laparoscopic procedures. We are presenting our experience of a young girl who underwent a laparoscopic biopsy of the hepatic hilum lymph-nodes for a suspected lymphoma recurrence. Due to her previous clinical history, the patient carried a central venous catheter (CVC). After 20 min from the beginning of the laparoscopic procedure, clinical symptoms were noticed: resuscitation maneuvers were immediately performed and foamy blood was aspirated from the CVC. After the patient was stabilized, the procedure was converted into laparotomy and concluded. Gas embolism is a described complication during laparoscopic procedures, but it is very rare in children where only 5 cases have been described, none registering the death of the patient.

Objective To report results of audiometric evaluations in high-risk congenital diaphragmatic hernia survivors and their exposure to audiological risk factors (mechanical ventilation, high frequency oscillation, aminoglycoside therapy and neuromuscular blocking agents). Design All newborns with high-risk congenital diaphragmatic hernia born between January 2003 and June 2009 were treated consecutively at the Neonatal Intensive Care Unit, Pediatric Hospital, University of Padova. Thirty-two survived and 26 of them underwent formal audiological evaluation (tonal and speech audiometry, otoacoustic emission, and immitance measurements) and follow up. Results Twenty-one children had normal hearing; 4 had conductive hearing loss, which was successfully treated; and 1 had severe sensorineural hearing loss and suffers from Turner syndrome. Conclusions Our series revealed a lower prevalence of sensorineural hearing loss in high-risk congenital diaphragmatic hernia survivors than in other studies, suggesting that the association between hearing loss and congenital diaphragmatic hernia has yet to be accurately defined and fully elucidated.

Background Intrapleural urokinase has been shown to be effective in the treatment of pleural effusions in children. However, optimal dosing in children is debated. The aim of this study was to prospectively evaluate a specific pediatric protocol of intrapleural urokinase. Methods All children admitted to a single institution over a 6-year period with a diagnosis of pleural empyema were managed with chest tube and fibrinolytics. Clinical data were collected prospectively. Urokinase (56,000 IU in 56 mL saline/m2 body surface) was administered twice daily, and was continued until resolution of the effusion. Further operative treatment was considered if urokinase treatment was unsuccessful after ≥3 days. Results are shown as median values (interquartile range). Results Forty-one consecutive children aged 4.4 (3.2–6.9) years were included in the study, and received 420,000 (280,000–750,000) IU of urokinase over 7 (4–8) days. Suction through the chest drain was applied for 8 (6-10) days, and IV antibiotics were discontinued after 12 (10–15) days from the start of intrapleural fibrinolytics. Four children (9.8%) required 5 additional operative procedures (3 thoracoscopic debridements and 2 minithoracotomic debridements). Patients were discharged after 13 (11–16) days from the beginning of intrapleural urokinase. No major side effects attributable to urokinase were observed. Conclusion Intrapleural instillation of urokinase according to a specific pediatric protocol results in a high success rate when applied as a primary treatment in children with pleural empyema. Administration of a size-adjusted dose of urokinase proved to be safe and could optimize drug utilization.

Background Mini-invasive techniques for gastroesophageal reflux disease (GERD), such as endoscopic injections of inert materials, have been introduced in recent years. However, results are still preliminary. Cell injection has emerged as an alternative strategy in both vesicoureteral reflux and incontinence. Here we report, for the first time, the injection of muscle precursor cells (MPCs) in the gastroesophageal junction (GEJ). Materials and methods MPCs were derived from expanded satellite cells isolated from skeletal muscle fibers of green fluorescent protein (GFP) positive mice. Via laparotomy, GFP-negative mice were subjected to cryoinjury of GEJ followed by injection of MPCs (experimental animals), bone marrow derived cells, or saline (controls). Results Immunofluorescence analyses of experimental GEJs demonstrated coexpression of GFP and desmin in grafted cells. GFP+ muscle neofibers were evident at 4 wk after injection. Coexpression of GFP and smooth muscle actin was also observed at 2 wk. Conclusions Satellite cells could be easily harvested, expanded in culture, and used as injectable substance in the GEJ. These results could be the background for the development of a new injection technique for GERD treatment, which might combine bulging and functional actions.

In the last decades, several studies regarding cardiopulmonary sequelae in survivors of congenital diaphragmatic hernia (CDH) have been published, but results often are conflicting, and controversies still exist. The aim of this study was to assess cardiopulmonary anatomic and functional outcome in a group of long-term survivors of CDH of mild to moderate degree.Twenty-four children aged 8.15 +/- 2.80 years underwent clinical examination with growth assessment, chest radiographs, echocardiography, pulmonary perfusion scintigraphy, static lung volumes measurement, and spirometry.Mean Z scores of weight for age and height for age were within normal values. Echocardiography showed normal anatomy and function in all but 3 patients with isolated CDH, in whom minor alterations were detected. Mean perfusion to the affected side was significantly lower (45.16 +/- 5.30%; P.0001) but still within normal range. Four children showed a substantial impairment of perfusion to the hernia side. The mean spirometric values and pulmonary volumes were normal. However, a mild restrictive pattern was evident in 6 children (27.3%), an obstructive pattern in 3 (13.6%), and a mixed obstructive and restrictive impairment in 1.Hypoplastic lungs of mild to moderate CDH survivors continue to cause pulmonary morbidity in some children many years after the correction of the defect. In particular, lung perfusion appears to be impaired in 20% of the patients and pulmonary function in 45%, without any significant cardiac or developmental sequelae. The negative correlation between FEV1 and duration of ventilation at presentation (r = -0.49; P =.026) may be caused by the consequences of lung hypoplasia, but initial ventilatory management may contribute to increased pulmonary morbidity. Relationship between perfusion and FEF25-75 (r = 0.61; p = 0.004) could reflect an equivalent degree of reduction in the caliber of distal airways and pulmonary vascular tree.