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Byline: Vito Briganti (1), Lucia Oriolo (1), Alessandro Calisti (1) Keywords: Antireflux surgery; Boix-Ochoa procedure; Gastroesophageal reflux; Oesophageal atresia; Oesophageal stricture Abstract: Introduction Oesophageal surgery for reflux stricture is as challenging in adults as in the paediatric age group. Several management protocols, both medical and surgical, are currently proposed, such as bougienage, funduplication without dilatation, funduplication with pre-- and postoperative dilatation, resection and interposition, and pharmacological therapy. However, reported results are not univocal. The aim of this work is to demonstrate that preoperative treatment with H2-antagonist combined with oesophageal dilatation and followed by anterior funduplication (Boix-Ochoa procedure with elongation of intraabdominal segment of the oesophagus) is a long-term, effective treatment for reflux stricture in children. It provides a tension free repair and an adequate protection to reflux, thus, preventing recurrences. Materials and methods In the last five years we observed oesophageal stenosis in 10 out of 49 children, operated for gastroesophageal reflux (mean age 62.9 months, range 12--156 months). All children underwent treatment with H2-antagonist (Ranitidine) and prokinetic agent (Cisapride), followed by oesophageal dilatations (mean 2.8, range 2--4 cycles) with Savary-Gillard dilators. An open anti--reflux procedure was performed (9 Boix-Ochoa and 1 Nissen) on children where a 9 mm endoscope passed easily through the oesophageal lumen. The pre and postoperative evaluation of all patients included symptoms assessment, esophagogram and endoscopy. Results Results were satisfactory in 9 patients. Only one patient where a Nissen wrap was performed, incomplete relaxation was documented radiologically. The patient required several dilatations for residual dysphagia before reaching a symptom free status. All other patients had an average follow-up of 38 months (range, 5 months to 5 years) with relief from dysphagia and no recurrence of stricture. Radiological controls showed good oesophageal lumens, with normally positioned neocardias, opening regularly during barium passage with no sign of reflux. Multiple biopsies from endoscopic controls confirmed complete relief from oesophageal stricture but persistence of Barrett's mucosa. Conclusions Our treatment of choice for reflux stricture is preoperative pharmacological therapy followed by series of dilatation with Savary-Gillard dilators till oesophagus is adequately dilated. Antireflux surgery is mandatory when a stricture is observed. We prefer a Boix-Ochoa funduplication with extensive transhiatal mobilization of thoracic oesophagus. This results in a 'tension free' fundoplication even when brachioesophagus is present. The procedure appears to be physiological for pediatric patients and in our hands was free from recurrences. Author Affiliation: (1) Pediatric Surgical Division, San Camillo-Forlanini Hospitals, Via Cicerone ndeg60, 00193 , Roma, Italy Article History: Accepted Date: 06/01/2003 Online Date: 05/09/2003

Abstract Background Meconium abnormalities are characterized by a wide spectrum of severity, from the meconium plug syndrome to the complicated meconium ileus associated with cystic fibrosis. Meconium Related Ileus in absence of Cystic Fibrosis includes a combination of highly viscid meconium and poor intestinal motility, low grade obstruction, benign systemic and abdominal examination, distended loops without air fluid levels. Associated risk factors are severe prematurity and low birth weight, Caesarean delivery, Maternal MgSO4 therapy, maternal diabetes. In the last 20 yrs a new specific type of these meconium related obstructions has been described in premature neonates with low birth weight. Its incidence has shown to increase while its management continues to be challenging and controversial for the risk of complicated obstruction and perforation. Materials and methods Among 55 newborns admitted between 1992-2008 with Meconium Related Ileus as final diagnosis, data about Low Birth Weight infants (LBW < 1500 g) were extracted and compared to those of patients ≥ 1500 g. Hischsprung's Diseases and Cystic Fibrosis were excluded by rectal biopsy and genetic probe before discharge. A softening enema with Gastrografin was the first option whenever overt perforation was not present. Temporary stoma or trans appendiceal bowel irrigation were elected after unsuccessful enema while prompt surgical exploration was performed in perforated cases. NEC was excluded in all operated cases. Data collected were perinatal history and neonatal clinical data, radiological signs, clinical course and complications, management and outcome. Results 30 cases with BW ≥ 1500 g had an M/F ratio16/14, Mean B.W. 3052 g, Mean G.A. 37 w Caesarean section rate 40%. There were 10 meconium plug syndrome, 4 small left colon syndromes, and 16 meconium ileus without Cystic Fibrosis. Five cases were born at our institution (inborn) versus 25 referred after a mean of 2, 4 Days (1-7) after birth in another Hospital (outborn). They were managed, after a Gastrografin enema with 90% success rate, by 1 temporary Ileostomy and 2 trans appendiceal irrigation. 25 cases with BW< 1500 g (LBW) had M/F ratio 11/14, Mean B.W. 818 g, Mean G.A. 27 w, Caesarean section rate 70%, assisted ventilation 16/25. There were 8 inborn and 17 outborn. Gastrografin enema was successful in 6 out 8 inborn infants only, all referred within one week from birth. There were 12 perforations mainly among late referred LBW outborn. Conclusions Meconium Related Ileus without Cystic Fibrosis responds to conservative management and softening enema in most of mature infants. In LBW clinical course is initially benign but as any long standing bowel obstruction management may present particular challenges. Clinical and plain radiographic criteria are reliable for making diagnosis and testing for Cystic Fibrosis may not be indicated. Enema may be resolutive when performed in a proper environment. Perforated cases may be confused with NEC which is excluded by clinical history, no signs of sepsis, lab signs missing, abdominal signs missing, typical radiological signs missing. The higher complication rate is recorded among cases delivered and initially managed in Neonatal Units without co-located Surgical Facilities. Early diagnosis and aggressive medical therapy may lead to higher success rate and help avoiding surgical interventions. Surgical therapy in uncomplicated cases, unresponsive to medical management, should be minimally aggressive.

Aims: The aim of this study was to examine 24 cases of obstetric brachial plexus palsy (OBPP) in 41,002 deliveries occurred at San Camillo-Forlanini Hospital in Rome, during the period 2000-2012.Materials and Methods: A population-based retrospective case-control study was designed and the database of the hospital was searched; for each case, maternal and fetal records were examined and some risk factors were evaluated.Results: A statistically significant association between the 24 cases OBPP and the following risk factors: primiparity (p < .014), birth weight (p < .002), maternal age (p < .02), diabetes (p < .03) and shoulder dystocia (p < .003) was found, moreover all the OBPP cases were recorded only in vaginal deliveries.Conclusions: The absence of OBPP cases in cesarean deliveries highlighted in this study supports the option of proposing an elective cesarean in the presence of known risk factors after a full disclosure with the mother of risks and benefits in order to obtain a valid consent. Furthermore, when cases of OBPP occur, communication between the physician and the parents of newborns is crucial and it may represent a valid risk-management tool to reduce malpractice lawsuits. [ABSTRACT FROM AUTHOR]

Gastroschisis is a congenital abdominal wall defect and its management remains an issue. We performed a review of the literature to summarize its evaluation, management and outcome and we describe a new type of surgical reduction performed in our center without anesthesia (GA), immediately after birth, in the delivery room. Between January 2002 and March 2013, we enrolled all live born infants with gastroschisis referred to the third-level Division of Obstetrics and Gynecology "San Camillo" of Rome. Two groups of infants were identified: group 1 in which gastroschis reduction was performed by the traditional technique and group 2 in which reduction was immediately performed after birth in the delivery room without GA. Twelve infants were enrolled in group 1, and seven infants in group 2. Statistical significance was observed between the groups regarding the hospital stay, for the duration of parenteral nutrition and full oral feeds (p = .004). Survival was similar between two groups. The reduction without GA performed immediately after birth in a delivery room encourages the relationship between the mother and her child and appears to be a safe and feasible technique in a selected group of patients with simple gastroschisis defect; for this reason, it could represent a valid alternative to traditional approach. [ABSTRACT FROM AUTHOR]

Objective: The finding of a fetal intra-abdominal cyst is relatively common and it can be due to a wide variety of clinical conditions. The aims of this study were to determine the accuracy of the prenatal ultrasound (US) in identifying the etiology of fetal intra-abdominal cysts and to describe the neonatal outcomes. Methods: All cases of fetal intra-abdominal cystic lesion referred to our center between 2004 and 2012 were reviewed. Cysts of urinary system origin were excluded. Prenatal and postnatal data were collected. Our cohort was divided into subgroups according to the prenatal suspected origin of the lesion (ovarian, mesenteric, gastro-intestinal and other locations). For each subgroup, sensitivity, specificity, positive predictive value, false-positive rate and accuracy of fetal US were calculated. Results: In total 47 fetuses (10/37 M/F) were identified. The mean gestational age at the time of diagnosis was 33 ± 4.9 weeks. Our cohort comprised of 25 ovarian cysts (10 simplex and 15 complex), 3 GI duplication, 6 mesenteric lesions, 4 meconium pseudocyst and 9 lesions of other origin. Surgery was performed in 38 cases (81%) at birth. The prenatally established diagnosis was exactly concordant with post-natal findings in 34 cases (72.3%). Sensitivity, specificity, positive predictive value and false-positive rate of US were 88.1%, 95.5%, 71% and 5.4%, respectively. Long-term outcome was good in almost 90% of the cases. Conclusions: The etiology of fetal intra-abdominal cysts can be prenatally diagnosed in about 70% cases. Despite the high risk of surgery at birth, the long-term outcome was good in most of the cases. [ABSTRACT FROM AUTHOR]