Cirugia pediatrica : organo oficial de la Sociedad Espanola de Cirugia Pediatrica最新文献

Introduction: Congenital bronchopulmonary foregut malformations are infrequent, with less than 60 cases reported. Group 3 or esophageal bronchus involves an abnormal origin of a lobar bronchus in the esophagus.

Clinical case: Patient with a history of heart disease requiring surgery and with left pulmonary hypoplasia. At 9 years of age, a chest CT-scan was carried out as a result of coughing following liquid intake. It revealed an esophageal bronchus of the right upper lobe. Given the history of pulmonary hypoplasia, a ventilation-perfusion scintigraphy was requested. It demonstrated lack of functionality of the right upper lobe. A right upper lobectomy was scheduled, with resection of the esophageal bronchus. 3D reconstruction was requested as part of preoperative planning. Following surgery, clinical signs disappeared, with an adequate respiratory function.

Discussion: Esophageal bronchus typically manifests in early childhood in the form of persistent atelectasis and repeated infections. However, in cases of stenotic bronchi, clinical signs may be unspecific, which requires multiple complementary tests and involves a high diagnostic suspicion. Late diagnosis usually leads to pulmonary resection. However, the latter is well tolerated even in patients with respiratory and cardiac pathologies. Patients with complex malformations benefit from preoperative planning with 3D reconstructions.

Introduction: The incidence of acute pancreatitis is increasing in the pediatric population. Up to 35% of children have recurrence secondary to anatomical variations of the pancreatic duct. In this context, endoscopic retrograde cholangiopancreatography (ERCP) stands as a key diagnostic and therapeutic tool.

Clinical case: We present two cases of recurrent acute pancreatitis (RAP) in 2 adolescents aged 14 and 15 years old. Apart from small gallstones in the gallbladder in one of them, bile duct or pancreatic duct disorders were not identified at either ultrasonography or nuclear magnetic resonance cholangiopancreatography (NMRCP). In both cases, diagnosis was established through ERCP, with two ERCPs required in each case before accurate diagnosis was achieved. ERCP had to be repeated as a result of technical issues in one case, and due to lack of relevant findings in the other. RAP episodes ceased after plastic prostheses had been placed in the pancreatic duct.

Discussion: TAnatomical variations of the pancreatic duct are a cause of RAP in the pediatric population. ERCP allows diagnosis to be established even when regular imaging studies are not conclusive.

Objective: To describe the use of contrast-enhanced ultrasonography in the diagnosis of anorectal malformations.

Material and methods: In 24 months, 5 patients aged 13 days-22 months were assessed by means of 6 colosonographies (colostograms or contrast-enhanced ultrasound enemas) as a result of suspected rectourethral fistula (3 boys) or rectovestibular fistula (2 girls). An ultrasound device with a dedicated software for contrast visualization, a multifrequency probe, and second-generation ultrasound contrast were employed. The results were confirmed using contrast-enhanced radiology in 4 patients, colostograms in 3 patients, and enema in 1 patient. There were no side effects.

Results: In 5 colosonographies, the fistulous tracts were visualized and located, and in 1, no fistula was observed. The rectal pouch/sacrum-coccyx relationship was assessed, and no presacral mass was detected. In 1 boy, the coccyx was absent. 2 patients had urological malformations.

Conclusions: Colosonography allows anorectal malformations and fistula presence, location, and tract to be assessed in real time, without ionizing radiation or side effects.

Objective: Morgagni hernia (MH) is a congenital diaphragmatic defect located in the retrosternal region. This study aims to report and analyze 20 years of experience in the diagnosis and management of MH at a tertiary pediatric center.

Material and methods: We conducted a retrospective review of patients who underwent laparoscopic MH repair between 2002 and 2022. Data on symptoms, defect location, surgical techniques, complications, and recurrences were analyzed.

Results: Fifty-five children were included in the study. Thirty-two (58%) were male. Mean age at surgery was 36 months (3 days-11 years). Mean follow-up was 45.16 months (8-110 months). Most hernias were discovered incidentally (61.8%). Nineteen patients (34.6%) had upper respiratory tract symptoms and a history of recurrent lung infection. Two patients (3.6%) presented with intestinal occlusion. Fifteen patients (27.2%) had Down syndrome, and seven (12.7%) had cardiac defects. The repair technique involved transabdominal laparoscopic-assisted repair with percutaneous sutures and extracorporeal knotting. Reoperation due to recurrence was necessary in two patients (3.6%), one of whom needed two redo procedures.

Conclusions: The transabdominal laparoscopic-assisted technique with percutaneous sutures and extracorporeal knotting is effective for MH repair, offering a low recurrence rate and minimal complications. Emphasizing the technical aspects, including tips and tricks, may further benefit the readership.

Introduction: Anal dilations (AD) following posterior sagittal anorectoplasty (PSARP) can have a psychological impact on patients and caregivers. We present our long-term results after changing the postoperative AD protocol to improve patient selection and avoid unnecessary ADs.

Material and methods: A retrospective study of patients undergoing PSARP in our institution from 2018 to 2023 was carried out. Demographic variables, ARM types, intraoperative Hegar (IH) and postoperative Hegar (PH) size after 3 weeks, need for dilations, and follow-up were reviewed. Protocol change includes outpatient measurement on postoperative week 3. If the caliber is lower than IH or than the normal caliber based on patient age, ADs are indicated.

Results: 36 patients (24 males) aged 8.2 ± 5.8 months at PSARP were included. The most frequent types of anorectal malformation (ARM) were rectoperineal (10), rectovestibular (10), and rectobulbar (10). IH size was 12 ± 1.2 mm. 3 weeks later, the caliber decreased in 29 patients (80.6%), with ADs being initiated in all of them. In 6 patients (16.7%), there were no differences in terms of size, which means ADs were not indicated. After a 40-month (range: 16-49) follow-up period, 6 (16%) patients had mucosal prolapse, with only 2 (5%) requiring surgical repair. None of the patients developed neoanal stricture.

Conclusions: The need for ADs following PSARP can be established based on outpatient neoanal measurement, by comparing neoanal size with IH size. Most patients require dilations, but there is a small group where the latter can be avoided without increasing the risk of stricture.

Introduction: Gastrointestinal stromal tumors (GIST) are infrequent in pediatric patients. The management of metastatic and irresectable tumors is usually non-surgical, with tyrosine-kinase inhibitors being the treatment of choice.

Clinical case: We present the case of a 14-year-old female patient with a metastatic and irresectable GIST treated with sunitinib that required surgery as a result of severe hemoperitoneum episodes with anemia and hemodynamic instability. A cytoreductive surgery with R2 resection margins was carried out. After a 10-year follow-up period, the patient remains under oncological treatment.

Discussion: The treatment of metastatic and irresectable GIST consists of tyrosine-kinase inhibitors. Evidence regarding the role of surgery remains limited, which means extreme caution should be exerted when indicating surgical treatment. However, surgery is still a useful tool within the array of therapeutic options.

Introduction: The incidence of choledocholithiasis in pediatrics has increased in the last 20 years. Treatment typically involves two procedures -endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC). The objective of this study was to demonstrate that conducting both procedures in a single step is safe in pediatric patients.

Material and methods: A prospective study was carried out in two Argentinian institutions over three years. Patients under 18 years of age diagnosed with choledocholithiasis were included. They were divided into two groups -surgery (one-step ERCP+LC) and control (two-step ERCP+LC).

Results: 42 patients were included. The surgery group consisted of 27 patients, whereas the control group was made up of 15 patients. Both groups were similar in terms of age and sex. The results showed that median anesthetic time was significantly shorter in the surgery group (120 minutes) than in the control group (150 minutes). 2 patients from the control group developed cholecystitis while awaiting LC.

Conclusions: Conducting ERCP+LC in a single step is safe in pediatric patients and can reduce anesthetic times as well as cholelithiasis morbidity and complications.

Objective: To describe the differences between voiding efficiency (VE) and other parameters of non-invasive urodynamic studies between patients with a history of posterior urethral valves (PUV) and patients without anatomical alterations of the lower urinary tract.

Material and methods: A retrospective case-control study was carried out from 2012 to 2022. Cases with a PUV history and controls without anatomical urethral alterations were included. Clinical variables, classic urodynamic parameters, lag time, and VE were collected. Student's t-test, Mann-Whitney U test, and Kruskal-Wallis' test were used to compare quantitative variables, whereas the chi-squared test was employed to compare qualitative variables.

Results: N= 100 (n= 50 cases and n= 50 controls). Age: 7.8 ± 3.73 years. The case group had greater postvoiding residual volume (9 ml vs. 3 ml; p= 0.025) and a longer lag time (3.7 ± 5.41 s vs. 2.6 ± 1.80 s; p= 0.006), as well as less VE (93.8% vs. 98%; p= 0.020), than the control group.

Conclusions: In patients with a history of PUV, alterations in urodynamic studies were more frequent than in controls. Voiding efficiency is an easily measurable urodynamic parameter that has not been implemented in regular practice in pediatric patients yet. Our data demonstrates that VE can be lower in PUV patients than in patients without anatomical urethral alterations.

Objective: To describe our experience with anorectal malformation (ARM) patients, while analyzing complications and risk factors.

Materials and methods: A retrospective study of ARM patients aged 0-18 years old undergoing surgery from 2006 to 2023 was carried out. Demographic variables, associated malformations, age and repair surgery operating times, presence and type of colostomy, previous intestinal preparation, and presence and type of surgical complications -intestinal occlusion, anal prolapse, stenosis, bleeding, dehiscence, extrusion, anoplasty misposition, urethral perforation, and stomal complications- were collected.

Results: 89 patients were studied. 44 patients were boys and 45 were girls. Median age was 7 years (3-18). Baseline treatment was posterior sagittal anorectoplasty (PSARP) in 61 (69%) patients, and colostomy in 24 (27%) patients (4/24 loop, 1/24 Hartmann, 19/24 divided ends). Median age at PSARP was 5.4 months (5 days-7 years), with a mean operating time of 112 min (38-259). The incidence of complications was 38% (34/89). The most frequent complication was anal prolapse (19%) (1/3 reintervention as a result of pain/bleeding), followed by dehiscence (17%). Statistically significant differences were noted between intestinal preparation (p= 0.001, -1.49 95% CI: -2.69 to -1.24), presence of colostomy (p= 0.05, -2,54 95% CI: -6.5 to -0.987), and age at surgical repair (p= 0.047, 1.198 95% CI: 1.1 to 3.15) with the incidence of complications. The age-complications correlation score was 0.21 (p= 0.046). No differences in terms of operating time (p= 0.073) and type of colostomy (p= 0.81) were observed.

Conclusions: 38% of the patients had complications. Intestinal preparation, presence of colostomy, and age at repair can have an impact on the incidence of complications. The first two could stand as protective factors (RR= -1,49 and -2.54, respectively). Age would increase the risk by 1.2-fold.