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Children with complex medical issues often present different comorbidities that cause feeding difficulties. Gastrostomy is often helpful, and should be performed when nutritional supplementation is necessary for longer than 6 weeks. Recently, different techniques have been used for gastrostomy in children. The authors report on their experiences regarding the diagnostic and therapeutic management of children requiring gastrostomy. All patients managed in the last 10 years were reviewed, retrospectively. Everyone underwent investigation to exclude gastroesophageal reflux disease (GERD). A total of 148 patients: 111 cases (75%) were neurologically impaired patients, 18 (12%) had complex heart disease, 10 (6%) had metabolic diseases, 4 (3%) had fibrosis cystic, 4 (3%) had muscle disease, and one had chromosomopathy. After investigation, 49 patients had GERD. PEG was performed in 101 cases (68%), laparo-assisted gastrostomy was performed in 44 cases (29.7%), open gastrostomy was performed in three cases. At follow-up, all patients reported weight gain, but 13 cases had major complications. Currently, the surgeon has the possibility of choosing between several safe techniques for gastrostomy. In our experience, PEG is the most useful technique for patients without GERD, while a laparo-assisted technique is better for patients who require laparoscopic fundoplication.

Midgut volvulus is a potentially life-threatening condition which is based on intestinal ischemia and reperfusion (I/R) injury. Remote ischemia conditioning (RIC) applied to a limb can protect distant organs such as heart and kidney. The aims of this study were to investigate the effect of RIC on a model of midgut volvulus and to explore its underlying mechanism of action. Six-weeks old C57BL/6 mice were studied: (a) sham (n = 4): laparotomy alone. (b) Intestinal I/R injury (n = 5): occlusion of the superior mesenteric artery (SMA) for 45 min followed by reperfusion. (c) Intestinal I/R (as in group above) with RIC immediately after reperfusion (n = 5). RIC consisted of 4 cycles of 5 min hind limb ischemia followed by 5 min reperfusion. 24-h after laparotomy, animals were euthanized, and the small intestine (same distance from cecum) was harvested. The intestine was examined for inflammatory cytokines (TNF-α and IL-6), epithelial proliferation marker Ki67 and stem cell marker Lgr5 expression. Compared to sham, the small intestine of IR mice had more intestinal damage, increased expression of inflammatory cytokines, decreased intestinal proliferation and stem cell activity. RIC significantly counteracted all these changes. Remote ischemia conditioning avoids intestinal damage due to I/R injury. This beneficial effect is associated with decreased intestinal inflammation and enhanced intestinal regeneration. This study implicates that RIC is a novel non-invasive intervention to reduce the intestinal damage occurring in midgut volvulus.

Introduction: The recycling of proximal stoma losses is known as a good practice to manage patients with high output stoma. In our center, we introduced this practice about 10 years ago. We revised our series before and after recycling protocol and we reviewed the literature. Methods: This is a retrospective study. We included all neonates who underwent ileostomy between 2000 and 2019. They were divided into two groups, Group A and Group B, before and after the introduction of recycling of stoma losses. Demographic data were included. Outcomes evaluated to demonstrate the efficacy of stools recycling were: weight at the time of anastomosis and at discharge, length of total parenteral nutrition, and time (expressed in days) between anastomosis and passage of the stools. Data were analyzed using Student’s t-test. P values Results: A total of 85 patients (29 females, 56 males) were included—Group A: 20 (24%) (13 males/7 females); Group B: 65 (76%) (43 males/22 females); Group A: 12/enterocolitis, 5/meconium-related ileum (MRI), 3/single intestinal perforation; Group B: 45 enterocolitis, 10/MRI, 8/single intestinal perforation, 1/an ileal atresia, 1/meconial peritonitis. Outcome about weight at anastomosis and discharge and about time of canalization were significant. Conclusion: We believe that the recycling of stoma losses is a safe and effective practice in neonates with ileostomy. Our technique of recycling is simple and practical. The benefit/risk rate is certain, in our opinion, in favor of the benefits as showed from our data.

The presence of a rare lesion for pediatric population, encountered in twins, as far as we know, is an exceptional event. The event made the management of a pathology, for which there are no guidelines in the pediatric field, even more delicate.Two twin sisters came to our attention, a short time after each other, due to the presence of a voluminous abdominal mass. After complete resection, the histological diagnosis was that of a paraovarian cystoadenofibroma.In pediatric surgery being minimally invasive is mandatory. However in selected cases the only objective, especially speaking of pediatric patients, ais to be radical and to protect the adnexal structures.

Bronchogenic Cysts (BCs) are benign congenital malformations commonly located in the mediastinum. In recent years the development of antenatal diagnosis has changed the BCs management allowing an earlier minimally invasive approach. We report a case of an asymptomatic 8-months-old girl with antenatal diagnosis of subcarinal posterior mediastinal BC. Thoracoscopic excision of the cyst was successfully performed. The management of antenatally diagnosed BCs is discussed. Thoracoscopic treatment of BCs is safe and effective with the advantage of a reduced morbidity compared to thoracotomy.

Activation of calcium/calmodulin-dependent protein kinase IV (CaMKIV) has been shown to increase intestinal injury and inhibit epithelial cell proliferation in dextran sulfate sodium (DSS)-induced colitis mice. However, the role of CaMKIV in necrotizing enterocolitis (NEC) is unknown. We aimed to study the expression and activation of CaMKIV in experimental NEC. Following ethical approval, NEC (n = 10) was induced in C57BL/6 mouse pups by hypoxia, gavage hyperosmolar formula feeding and lipopolysaccharide from postnatal days P5 to 9. Breastfed pups served as control (n = 10). Mouse pups were sacrificed on P9 and the terminal ileum was harvested. Gene NEC injury was scored blindly by three independent investigators. CaMKIV, CREM and IL17 gene expression, and CaMKIV and pCaMKIV protein expression were assessed. The data were compared using Mann–Whitney U test. P

Introduction There is a need to develop sensitive markers to diagnose or monitor the severity of intestinal damage in necrotizing enterocolitis (NEC). Mitochondrial deoxyribonucleic acid (mtDNA) is increased in the intestine and blood of adults in response to intestinal ischemia and can trigger secondary organ damage. We hypothesize that mtDNA is increased during experimental NEC and that mtDNA levels are correlated to the degree of intestinal injury. Materials and Methods NEC was induced in C57BL/6 mice (n = 18) (approval: 44032) by gavage feeding with hyperosmolar formula, hypoxia, and lipopolysaccharide administration from postnatal day (P) 5 to 9. Breastfed pups served as control (n = 15). Blood was collected by cardiac puncture and terminal ileum was harvested on P9. Reverse transcription quatitative polymerase chain reaction was used to measure mtDNA (markers COX3, CYTB, ND1) and inflammatory cytokines (interleukin 6 [IL-6] and tumor necrosis factor-α[TNF-α]) in blood and ileum. Intestinal injury was scored blindly by four investigators and classified as no/minor injury (score 0 or 1) or NEC (score ≥2). Results mtDNA is significantly increased in gut and blood of NEC mice (p Conclusion Following NEC intestinal injury, mtDNA is released from the intestine into circulation. The blood level of mtDNA is related to the degree of intestinal injury. mtDNA can be a novel marker of intestinal injury and can be useful for monitoring the progression of NEC.

In the last decade, the applicability of robotic surgery has been demonstrated in many interventions, expanding the indications of minimally invasive surgery also to pediatrics. The aim of the study is to evaluate postoperative pain to demonstrate better control following robotic procedures compared to thoraco-laparoscopic surgery. An observational, retrospective, multicentre study was performed involving 204 children undergoing robot-assisted surgery and thoraco/laparoscopic surgery at the Istituto Giannina Gaslini in Genoa and the Siena University Hospital (2013-2017): 83 children underwent robotic-assisted surgery and 121 thoracic-laparoscopic surgery. Personal data and type of intervention were assessed, dividing the patients into four categories: thoracic, gastrointestinal, hepatobiliary and urological surgeries. We analyzed the anesthetic risk according to ASA classification by type of intervention, the type of anesthesia used, the anesthetic drugs used during surgery and in the postoperative period. Both the problems that occurred during the procedures and the number of interventions converted into open during robotic surgery and laparoscopic thoracic surgery were analyzed. Pain was measured on the 1st, 2nd and 3rd day (FLACC or NRS scales). By comparing the two groups (robotics-non-robotics), the analysis shows that postoperative pain does not change with the chosen approach, but always maintains very low values, typical of minimally invasive surgery. The pain score is significantly higher in patients undergoing thoracic surgery, either robotic or thoracoscopic, compared to those undergoing gastrointestinal surgery (P corrected according to Bonferroni: 0.0006) and those undergoing urological intervention (P corrected according to Bonferroni: 0.04). In conclusion, no significant change in the intensity of postoperative pain between the two groups was found, while it is seen that the pain in patients undergoing thoracic interventions (robotic/thoracoscopic) is more intense than that reported for other types of interventions.

An association between malrotation and congenital duodenal webbing is rare. We present our experience with four patients at two centers, and a review of published reports. There are currently 94 reported cases of duodenal pathology associated with malrotation. However, only 15 of the 94 cases (15.9%) include patients with malrotation and a duodenal web. We suggest that nonbilious vomiting in a child must prompt the surgeon to consider duodenal pathology even in the presence of malrotation.

Introduction Necrotizing enterocolitis (NEC) is a devastating intestinal illness in premature infants characterized by severe intestinal inflammation. Despite medical interventions, NEC mortality remains alarmingly high, which necessitates improved therapies. Lactoferrin is among the most abundant proteins in human milk and has important immunomodulatory functions. While previous studies have indicated protective effects of lactoferrin against neonatal sepsis and NEC, the underlying mechanism remains unclear. We hypothesize that lactoferrin downregulates inflammation and upregulates proliferation in intestinal epithelium during NEC injury. Materials and Methods NEC was induced by hypoxia, gavage feeding of hyperosmolar formula and lipopolysaccharide between postnatal day P5 and P9 (n = 8). Breastfed mice were used as control (n = 7). Lactoferrin (0.3 g/kg/day) was administered once daily by gavage from P6 to P8 in both NEC (NEC + Lac; n = 9) and control mice (Cont + Lac; n = 5). Distal ileum was harvested on P9 and analyzed for disease severity, inflammation, and proliferation. Groups were compared using one-way ANOVA and t-test appropriately; p Results Compared to NEC group, lactoferrin-treated NEC mice had reduced disease severity, reduced inflammation markers IL-6 and TNF-α expression and increased intestinal stem cell marker Lgr5 + expression. Lactoferrin-treated NEC mice exhibited increased nuclear β-catenin, indicating upregulated Wnt pathway, and increased Ki67 positivity, suggesting enhanced proliferation. Furthermore, lactoferrin administration to control mice did not affect intestinal inflammation as well as Lgr5 + stem cell expression and epithelial proliferation. This supports the safety of lactoferrin administration and indicates that the beneficial effects of lactoferrin are present when intestinal injury such as NEC is present. Conclusion Lactoferrin administration reduces the intestinal injury in experimental NEC by downregulating inflammation and upregulating cell proliferation. This beneficial effect of lactoferrin in stimulating cell proliferation is mediated by the Wnt pathway. This experimental study provides insights on the mechanism of action of lactoferrin in NEC and the role of lactoferrin in enteral feeding.

Torsion of an epididymal cyst is an extremely rare cause of acute scrotum in children and in young boys. Its reported incidence is 5-20%. The treatment is usually conservative. Many cases (up to 60%) regress spontaneously, especially if below 3 cm. Few cases have been reported in Literature (7 cases/2018). We add our patient as eighth case. He was a 13-year-old boy who was admitted for acute scrotum. Ultrasound excluded torsion of the testis and he was managed for 5 day conservatively. Based on clinical history and physical exam, we decided to perform a prompt surgery that revealed a torsion of epididymal cyst that was confirmed by histological exam.

Background: Congenital pouch colon (CPC) is an unusual malformation associated with anorectal malformations (ARMs) that are seen especially in Asia. The aim of this study was to analyse our series of CPC associated with ARM in our centre and report our experience based on the rarity of pathology. Materials and Methods: This is a retrospective study conducted at the Department of Paediatric Surgery in North Iraq. We identified patients from a prospectively kept database, including all patients managed between 1997 and 2014. Results: In total, 17 patients (3 females and 14 males) were included; all had CPC and high ARM; male:female ratio was 5.6:1. Two females had colo-vestibular fistula, 1 had a colo-cloacal fistula, all males had imperforate anus with colovesical fistula. Pre-operative diagnosis of CPC was made in eight patients (47%). Four patients (23.5%) had an incomplete pouch colon (Type III and IV), and 13 (76%) had complete pouch colon (Type I and II). All patients were managed with staged surgery. Mortality rate was 17.6% (3/17). Conclusions: CPC associated with ARM can be defined as 'Asian' complex malformation. Few cases are reported in Literature from Europe and USA. However, it is known that it is ever more frequent the collaboration between Asian and European surgeons (as in our study), so the suspicion should be considered in all patient high ARM who come from Asian region. We reviewed literature and report our experience of 15 years, after a retrospectively analysis, to share it and add our data to their reported.

The repair of esophageal atresia (EA) carries an increased risk of anastomotic leak and stricture formation, especially in patients with anastomotic tension. To minimize this risk, pediatric surgeons perform elective post-operative muscle paralysis, positive-pressure ventilation, and head flexion (PVF) to reduce movement and tension at the anastomosis. We systematically reviewed and analyzed the effect of post-operative PVF on reducing anastomotic complications. Embase, MEDLINE, Web of Science, and PubMed databases were used to conduct searches. Articles reporting pediatric EA undergoing primary anastomosis, anastomotic complications, and comparisons between patients who received post-operative PVF to those who did not were included. Odds ratios (OR) for all post-operative anastomotic complications were calculated using random effects modelling. Three of the 2268 papers retrieved met inclusion criteria (all retrospective cohort studies). There were no randomized controlled trials. Post-operative PVF showed a significant reduction in anastomotic leak (OR 0.07; 95% CI 0.01–0.35) when compared to no PVF. Stricture formation was not statistically different between groups. Potential sources of bias include patient allocation. Based on available data, our analysis indicates PVF may reduce anastomotic post-operative leak. To confirm these results, a prospective study with clearer definitions of treatment allocation should be performed.

Background: Phimosis is a condition in which the foreskin cannot be portrayed on the glans. It is a physiological and common condition in the pediatric age. The pathological form derives from an inflammatory or traumatic lesion. Circumcision is the most common surgical treatment of phimosis but it is a controversial practice, especially in occidental world. Methods: We enrolled 61 patients with pathological phimosis (22/balanoposthitis, 18/painful erection, 21/ urinary discomfort) between 2015–2017. Results: All patients underwent preputialplasty. Conclusions: Various alternatives to circumcision have been described, as manual retraction therapy, topical steroid therapy, and many types of preputialplasty. We report our technique.

Duplications of the alimentary tract are rare malformations, and ileum is the most involved intestinal tract. During fetal life, they are usually occasional findings and may be asymptomatic until adulthood. We present the clinical case of volvulus on ileal cystic duplication diagnosed by ultrasound during prenatal follow-up. Case report: Diagnosis of cystic ileal duplication was made by ultrasound at our center at 23 weeks of gestational age, which was confirmed with fetal MRI. During follow-up, at 36 + 4 weeks, the presence of dilated loops with reduction of peristalsis was shown by ultrasound, so that, despite stable fetal parameters, an emergency caesarean delivery was programmed for suspected volvulus. After being stabilized, the patient underwent to laparotomy that revealed ileal volvulus at 2 cm from the ileo-cecal valve on a cystic duplication. Cyst and necrotic loop (10 cm) was resected and was performed an anastomosis. Patient started feeding on VII post-operative day, and was discharged on the X day. Patient is on follow up and present good conditions. Discussion: Diagnosis of intestinal cystic mass in prenatal period requires a close follow-up because the risk of a volvulus. According to the literature, even in the presence of stable fetal parameters, the presence of dilated loops and the absence of peristalsis are signs that must suspect the presence of a mechanical occlusion for which timely treatment is necessary to reduce mortality and morbidity. Keywords: Prenatal ultrasound, Volvulus, Ileal duplication

The management of choledochal cysts has evolved during the last 3 decades. Laparoscopic surgery has revolutionized the treatment of choledochal cyst (CC). We report our case, 2-year old female, in which total excision of cyst and Roux-en-Y hepaticoenterostomy is done by laparoscopic approach. In the hands of experts, laparoscopic excision of the CC is safe and effective approach. This is our first experience and our outcome has been good to a follow-up of 6 months. In our opinion, laparoscopic surgery is a safe treatment of choledochal cyst with less postoperative morbidity, a shorter length of stay and a lower blood loss when compared with open approach. Laparoscopic surgery may become the first choice procedure for choledochal cyst.

Introduction Burkitt’s lymphoma is a high grade B-cell tumor described for the first time by the Irish surgeon Dennis Burkitt in 1958 in Africa. The most frequent of the clinical variants, in which it is classified by the World Health Organization (sporadic, endemic, HIV-associated), is the sporadic one, which usually involves the abdomen, in particular the ileocecal tract. Thus, a common clinical presentation is that of a child suffering from abdominal pain with nausea and vomit, until the dramatic case of an intestinal occlusion by an intussusceptions. According to this, the surgeon is the first who diagnoses and treats this tumor, playing an important role for the treatment, in terms of reduction of the metabolic complications of the medical therapy and of improvement of survival rate. In this work we present a case of a child operated for intestinal occlusion by ileoileal intussusception, caused by a Burkitt’s lymphoma, as it was diagnosed by histological examination few days after surgical intervention. Case report A 12-years boy reached the emergency department for abdominal pain and vomit. Two weeks before he had a surgical intervention for a suspected appendicitis at another hospital. An ultrasound examination was performed and it revealed the presence of a complex mass in the right iliac fossa. The day after the patient felt worse and he had an episode of bilious vomit. An x-ray examination of the abdomen was performed and showed the presence of an intestinal obstruction. The patient underwent to surgical intervention. The obstruction was caused by an ileoileal intussusceptions, and it needed to perform a resection followed by anastomosis. Few day after surgical intervention, the result of histological examination indicated the presence of a Burkitt’s lymphoma within the tract resected. A CT scan was performed and showed the involvement of mesenteric lymph nodes. The bone marrow aspirate and the lumbar puncture showed no neoplastic presence. Then the patient started therapy according to protocol. Discussion and Conclusions Burkitt’s lymphoma represents 3-5% of all non-Hodgkin lymphomas, and 40% in pediatric population. Children have an excellent prognosis with contemporary treatment regardless of the disease stage. Patients with limited stage disease are curable with limited treatment, avoiding complications associated with more intensive therapies. Nevertheless surgery is important in the management of this disease, the role of the surgeon has usually been controversial. A surgical intervention can be resolving in case of limited disease, or, in case of a high stage disease, it can be diagnostic or helpful, through the debulking of the mass. However, apart in case of intussusception, the diagnoses of Burkitt can be challenging and the presence of disease can revealed after a story of recurrent abdominal pain or after surgical interventions for appendicitis. In this work we show how a timely diagnosis can be difficult and how it can be an obstacle for treatment. In this case the sudden worsening of clinical conditions permitted an early diagnosis with a complete resection of the ileum involved by Burkitt’s lymphoma has improved the prognosis and reduced therapy’s complications.

Background: In the last 30 years mini-invasive surgery (MIS) has been widely used becoming an important and irreplaceable method, safe and highly reliable, in both the diagnostic and therapeutic treatment, for a variety of conditions in both the child and the newborn. This has led to a significant increase of the use of this approach in the pediatric population under the age of 3 years, with results similar to the open techniques. Materials and Methods: At the Department of Surgery, Medicine and Neuroscience at the University of Siena we conducted a retrospective study of patients aged less than three years of life underwent minimally invasive procedures. The clinical information was extrapolated from a prospective database. They included all patients treated from June 2003 to October 2014. Were considered for each patient demographics, associated diseases, surgical procedure, MIS approach, the instruments used, the duration of surgery and hospitalization, intraoperative and postoperative complications (early and late). Results: From a total of 933 minimally invasive procedures, 150 (16%) were performed under the age of 3 years. The 76% of patients were males, 24% were females. Twenty-two patients (15%) presented associated diseases. 53 (35%) were diagnostic procedures, 97 (65%) were therapeutic procedures. We treated: 1 3 esophageal atresia, 1 diaphragmatic hernia, 1 congenital cystic adenomatoid malformation (CCAM), 8 stenosis of the ureteropelvic junction , 2 disorders of sexual differentiation (DSD), 20 inguinal hernias, 75 cases of non-palpable testis, 15 cases of Hirschsprung disease, 10 cases of fundoplication, 4 cases of ovarian tumors, 6 cases of nephrectomy, 4 cases of eminefrectomy and 1 case of thymoma. In total we performed 6 (4%) thoracoscopic procedures, 18 (12%) in retroperitoneoscopy and 126 (84%) in laparoscopy. 55 procedures (37%) were performed in "one-trocar" technique. Among the remaining 95 (67%), in 62 (41%) we used a “3 mm” instruments, in 18 (12%) “5 mm” instruments and in 15 (14%) they were mixed (3/5 mm). The duration of the procedure was an average of 59 minutes (range: 20-135 minutes) in diagnostic procedures and 184 minutes (range: 40-370 minutes) in the therapeutic procedures. We converted to an open technique in 14/150 (9%). We reported no postoperative complication and incidentaloma no intraoperative complications. The following is 100% survival. Conclusions:MIS is probably the most important change that has taken place in the field of Pediatric Surgery in the last 30 years. The optimum benefits are to be found in the lesser surgical stress, the lower cavity contamination, the magnification of details, the reduced hospital stay, reduced morbidity or the best aesthetic result.

Introduction Duodenal atresia Windsocks type is a rare condition of congenital bowel obstruction. Thanks to recent technological advancements of prenatal diagnosis it is possible to make a diagnosis of duodenal atresia with high degree of certainty through the radiological sign of “double bubble”, but up to date it is not yet possible to identify the type of duodenal atresia. We report the case of a patient with prenatal diagnosis of “double bubble”. The patient had no other concomitant malformations. Case Report The patient came to our attention after prenatal ultrasound that showed a picture of double bubble. At the 27th week of gestation we performed fetal MRI that confirmed the US pattern of double bubble but it did not identify with certainty the type of duodenal atresia. At birth the patient underwent GI rx examination that showed a picture of partial duodenal obstruction compatible with the Windsocks type. On the following day, we performed endoscopy which showed the presence of duodenal membrane, so the patient underwent surgical treatment with a longitudinal duodenal incision in order to treat the wind-sock membrane. After one month a further Upper-GI rx examination showed a regular transit of the contrast. Four months after the first operation the patient underwent new surgical treatment for bowel obstruction by adhesions. The operation was successful and the patient had a complete recover.Conclusions Patients with prenatal diagnosis of “double bubble” require a multidisciplinary approach for proper clinical management. Unfortunately it is not currently possible to identify with certainty by prenatal ultrasound the type of duodenal atresia, but in case of incomplete bowel occlusion , the possibility of an atresia Windsocks type should always be considered, especially for setting the right surgical approach.

Introduction: Hypospadias is one of the most common birth defects that affect the male urogenital tract. It can present as isolated anomaly, but sometimes can arise in the context of complex disorders of sex development (DSD). These malformations are characterized by a great variety of clinical manifestations and compromise the aesthetic appearance, but also functional and psychological impact that the malformation can determine the patient. Materials and Methods: We conducted a retrospective study of patients undergoing surgery for hypospadias from March 2000 to January 2015. The data was extrapolated from a prospective database. It was considered for each patient: demographics; type of hypospadias; surgical technique; average age for surgery; intraoperative and postoperative complications (early and late). Duckett’s classification was used. Results: 343 urethroplasties were performed. 320 (93%) were primary urethroplasties and 23 (7%) reoperations in patients who had performed many other surgical procedures. 7 patients with megameatus were excluded. The hypospadias have been ranked according to Duckett’s classification, 35 patients had associated diseases. In total were performed: 186 (55%) Snodgrass, 71(21%) Duckett,10 (3%) augmented Duckett, 42 (13%) Magpi, 16 (5%) Duplay, 1 (0,3%) Bracka, 1 (0,3%) was a Bianchi’technique and 5 (1,4%) were Standoli. In 4 patients (1%) were used mixed technique. There were no intraoperative complications. The mean age at surgery was 15 months (range 12-22 months). Postoperative complications were 12%. Long term follow up was done with uroflussimetrie at 3 and 6 months in those who had reached the continence and possible urethral calibrations in those who had submitted a stenosis in post-op.Conclusions: The improvement of surgical techniques, the use of optical amplification tools, the use of suture material (PDS) and the experience gained in recent years have enabled us to optimized the results. Though aware of the potential and actual complications that this type of microsurgical correction can lead to the results we have obtained are comparable to those of major international series and can be considered satisfactory, both from an aesthetic and functional.