Thymic cysts are rare embryonic remnants along the course of thymic migration in the neck or the anterior mediastinum which may result in cervical masses in children, often misdiagnosed. We present the experience gained by three European tertiary care medical centers in the treatment of thymic cysts as well as the current data on the embryology, clinical presentation, diagnosis and management of thymic cysts. A retrospective study was carried out in nine patients with thymic cysts during the period 1986-2002 at the departments of Pediatric Surgery of Children's University Hospital "Federico II" and "Santobono" Pediatric Hospital of Naples in Italy and "Aghia Sophia" Children's Hospital of Athens in Greece. All cases were asymptomatic, appearing mainly as masses resembling branchial cyst or lymphatic malformation. Laboratory and imaging investigations were not useful for preoperative diagnosis. In one case the mass extended into the mediastinum. The histological findings of thymic tissue and Hassal's corpuscles in the cystic wall were diagnostic. In all cases, surgery was successful and uneventful. Surgical excision was accomplished by dissection of the cystic masses from the jugular vein, carotid artery and vagus nerve and from the sternocleidomastoid muscle. The presence of a normal thymus in the mediastinum must be documented preoperatively in order to avoid the risk of total thymectomy. If a cervical thymic cyst extends into the normal thymus, attempts should be made to preserve the thymus, especially in younger patients. Thymic cysts should always be included in the differential diagnosis of lateral cervical masses, especially in children.

Fig 1-Mean changes in blood flow, diastolic diameter, and distensibility ofbrachial artery in 12 diabetic subjects and 12 controls during reactive hyperaemia, 1Oug glyceryl trinitrate, and 400 ,ug glyceryl trinitrate. Bars show 95% confidence intervals (9) mm Hg; blood flow 45 (28) v 49 (41) m/min; diastolic diameter 482 (0 60) v 4-47 (1P05) mm; distensibility 4-8 (1-4) v 5 9 (1-6) per kPa). During reactive hyperaemia, heart rate, blood pressure, and the increase in brachial artery blood flow (5548% (99 5%) v 590% (106&6%)) were similar in diabetic and normal subjects (figure 1) but the increases in brachial artery diastolic diameter (1 2% (2-7%) v 9-1% (4-4%); difference 6-9% (95% confidence interval 4.9% to 11%)) and distensibility (-15-3% (10-4%) v 31% (31-7%); difference 46-3% (25-5% to 67<1%)) were significantly less in diabetic subjects (both P < 0-00 1). After 10 ,ug glyceryl trinitrate or 400 ,ug glyceryl trinitrate the increase in flow, diameter, and distensibility was similar in diabetic and normal subjects (figure 1). 700-Comment Endothelium dependent, flow related dilatation and increase in distensibility of the brachial artery are greatly impaired in patients with non-insulin dependent diabetes, but endothelium independent responses induced by glyceryl trinitrate are similar to those in normal subjects. Loss of flow related increase in arterial distensibility will augment systolic pressure, myocardial wall stress, and heart work relative to stroke output, potentially promoting left ventricular hypertrophy and lowering ischaemic threshold. Late systolic pressure will be further augmented by early wave reflection from the periphery3 because pulse wave velocity is increased when distensibility is reduced. Loss of flow mediated vasodilatation reflects endothelial dysfunction and may thus also provide a marker of atherogenetic susceptibility. Our data provide evidence ofvascular dysfunction in non-insulin dependent diabetes before the appearance of microalbuminuria, previously regarded as its earliest marker.4We thank Dr J R Peters for allowing us to study patients under his care and Wendy Simons and Julie-Ann Davies for their secretarial assistance.Funding: British Heart Foundation. Conflict of interest: None.

The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.

No abstract

Introduction This is the report of the first official survey from the Italian Society of Pediatric Surgery (ISPS) to appraise the distribution and organization of bedside surgery in the neonatal intensive care units (NICU) in Italy. Methods A questionnaire requesting general data, staff data and workload data of the centers was developed and sent by means of an online cloud-based software instrument to all Italian pediatric surgery Units. Results The survey was answered by 34 (65%) out of 52 centers. NICU bedside surgery is reported in 81.8% of the pediatric surgery centers. A lower prevalence of bedside surgical practice in the NICU was reported for Southern Italy and the islands than for Northern Italy and Central Italy (Southern <Northern<Central, p < 0.03). The most frequent clinical characteristics of neonates was preterm neonates with birthweight < 1200 g, with cardiorespiratory instability and/or ventilatory dependence. The most frequently selected indications to surgery were pneumothorax, pleural effusion, pericardial effusion, central venous catheter (CVC) positioning, intestinal perforation, patent ductus arteriosus ligation and congenital diaphragmatic hernia. More than 60% of respondents report no institutional recommendations and dedicated informed consent on bedside surgical procedures. The lack of dedicated areas and infrastructures is considered a relative contraindication to the performance of bedside surgery. Conclusion Bedside surgery is performed in the majority of the Italian pediatric surgery centers included in this census. The introduction of a national set of surgery guidelines would be widely welcomed.