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

Objective: To find out whether the use of indocyanine green for lymphatic sparing in the laparoscopic Palomo technique reduces the incidence of postoperative hydrocele.

Materials and methods: A comparative cohort study of varicocele patients treated with the laparoscopic Palomo technique from 2008 to 2023 was carried out. Patients were divided into two groups according to whether fluorescence lymphography (intratesticular indocyanine green) had been performed or not. Epidemiological, surgical, and clinical data, as well as complications, were recorded. A hypothesis test was conducted using the SPSS software.

Results: 30 patients undergoing varicocele surgery through the laparoscopic Palomo technique were included. They were divided into two groups -lymphatic sparing (n= 13) vs. spermatic vessel ligation without sparing (n= 17). Mean age at surgery was 14 years. 5 cases of postoperative hydrocele were identified in the no lymphatic sparing group. 1 of them required surgery for hydrocele treatment. No hydrocele cases were noted in the lymphography group. The difference was statistically significant (p= 0.032). There were no statistically significant differences in terms of operating times or mean hospital stay. No recurrences, postoperative testicular atrophies, or indocyanine-green-related complications were recorded. Mean follow-up was 11.4 months.

Conclusions: The use of indocyanine green for lymphatic sparing in the treatment of varicocele through the laparoscopic Palomo technique significantly reduces the incidence of postoperative hydrocele.

Introduction: Preoperative application of botulinum toxin type A has demonstrated to be safe and effective in the closure of complex ventral hernias in adults. However, its use in pediatrics has been little documented.

Case report: We present the case of a 22-month-old girl with a complex abdominal wall ventral hernia secondary to multiple neonatal laparotomies. In a first procedure, botulinum toxin was administered using an intramuscular approach at six sites of the muscle layers surrounding the defect, under general anesthesia and ultrasound control. 4 weeks later, an open hernia repair was conducted, without complications.

Discussion: Botulinum toxin at low doses could facilitate the surgical treatment of complex ventral incisional hernias in children. Even though it is important to adjust dosage and anatomical reference points according to hernia type and patient age and weight, further studies are required to optimize these variables.

Introduction: Surgical exploration in complete ureteropelvic-junction disruption (CUPJD) is still recommended by many authors. Conservative approach to pediatric renal trauma (RT) includes minimally invasive techniques such as nephrostomy, angioembolization or double-J stent placement.

Case report: A 14-year-old patient with CUPJD was treated conservatively. CT-scan revealed active bleeding of the renal artery and significant urine extravasation. Coil angioembolization and nephrostomy placement were performed. An attempt to place a double-J stent was unsuccessful and surgical reconstruction was scheduled. Before surgery, methylene-blue was injected through the nephrostomy observing blue urine output through urethra. Antegrade pyelogram revealed drainage from the urinoma to the ureter. A new attempt to place an internal-external double-J-stent was successful. After 5 weeks, it was removed with total restoration of the urinary tract.

Conclusion: Complete urinary tract restoration in some cases of CUPJD following RT is possible through a nonoperative approach. It can be safe and effective, reducing the risk of complications associated with complex surgeries.

Objectives: To reduce the overuse of magnetic resonance cholangiopancreatography and the rates of non-therapeutic endoscopic retrograde cholangiopancreatography in pediatric patients suspected of choledocholithiasis.

Materials and methods: Retrospective study of patients suspected of choledocholithiasis between January 2010 and June 2023. Patients with cholangitis or two or more of the following predictive factors of choledocholithiasis in initial laboratory tests and ultrasound were categorized as high-risk group: total bilirubin level ≥ 2 mg/dl, common bile duct > 6 millimeters on ultrasound; and detection of choledocholithiasis by ultrasound. Patients were recategorized according to the results of the second set of laboratory and ultrasound analysis. Confirmatory modalities (magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and/or intraoperative cholangiography) were used to evaluate the presence of choledocholithiasis. Finally, we assessed the predictive capability of both the initial high-risk group and the group after recategorization.

Results: A total of 129 patients were included. After initial studies, 72 (55.8%) patients were classified into the high-risk group. After recategorization, only 29 (22.5%) patients were included in this group. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the initial high-risk group were 89.3%, 53.5%, 34.7%, 94.7%, and 61.2%, respectively, while after recategorization, they were 82.1%, 94.1%, 79.3%, 95.0%, and 91.5%, respectively.

Conclusions: Recategorization of the risk of choledocholithiasis would significantly improve the diagnostic accuracy of choledocholithiasis and help reduce the overuse of more complex and unnecessary studies/procedures.

Introduction: Intestinal obstruction secondary to the use of fortified milk is a rare cause in pre-term patients.

Case report: We present the case of a female pre-term newborn admitted as a result of abdominal distension and rectal bleeding, which mimicked necrotizing enterocolitis. On abdominal X-ray, she had an obstruction pattern, and on ultrasonography, echogenic masses at the distal ileum were observed. Given the lack of improvement with conservative management, urgent exploratory laparotomy was decided upon. At surgery, compact milk masses at the level of the distal ileum were identified as the cause of intestinal obstruction. Appendicostomy and lavage with saline solution through the ileocecal valve were performed. This allowed milk masses to come out towards the colon, and a great amount of acholic stools to be expelled.

Conclusion: The increase in "milk curd syndrome" cases should lead us to consider this cause in the differential diagnosis of intestinal obstruction in pre-term newborns fed with fortified milk.

Objective: To analyze the efficacy of intralesional steroid treatment in refractory caustic esophageal stricture.

Materials and methods: An analytical, retrospective study of patients receiving intralesional steroid treatment with triamcinolone acetonide as a result of refractory caustic esophageal stricture was carried out. Demographic variables, stricture characteristics, number of dilations, steroid injections, and dilation score (no. of dilations/follow-up period in months) pre- and post-treatment were collected. Stricture characteristics (diameter and length) and dilation score pre- and post-treatment were compared using the T-Test or Wilcoxon test.

Results: N= 5. Median age: 5 years (17 months-7 years). Follow-up: 6.60 ± 2.70 years. Swallowed products included NaOH, KOH, and ClH. Zargar classification at follow-up initiation was IIb (n= 2), IIIa (n= 1), and two chronic strictures. 6.6 ± 9.23 esophageal dilations were carried out before steroid treatment initiation. The mean number of intralesional therapy sessions was 11.20 ± 6.14. Stricture length decreased by 3.60 ± 2.63 cm (t= 3.06; p= 0.019). No differences were found in terms of diameter increase: -1.60 ± 3.58 mm (t= -1.00; p= 0.187). The dilation score diminished from 1.47 ± 0.86 to 0.47 ± 0.18 dilations per month of follow-up (Z= -2.02; p= 0.043).

Conclusions: Even though there is limited evidence available in the pediatric population, intralesional triamcinolone treatment is seemingly useful in the treatment of refractory caustic esophageal stricture, since it reduces length and dilation score.

Introduction: The indication of preoperative prophylaxis in the insertion of indwelling tunneled central venous catheters (ITCVC) has a low level of evidence. Our objective was to assess risk factors of ITCVC-related early bacteremia in oncological pediatric patients and to determine the need for preoperative prophylaxis.

Materials and methods: A univariate and multivariate retrospective analysis of patients in whom an ITCVC was placed from January 2020 to July 2023, according to whether they had ITCVC-related early bacteremia (EB) in the first 30 postoperative days, was carried out. Demographic variables, leukopenia, neutropenia, use of preoperative antibiotic prophylaxis, and history of central venous catheter (CVC) or bacteremia were collected. Calculations were carried out using the IBM SSPS29® software.

Results: 176 patients with a mean age of 7.6 years (SD: 4.82) were analyzed. 7 EB cases were identified, with a greater frequency of neutropenia (p= 0.2), history of CVC in the 48 hours before insertion (p= 0.08), and intraoperative CVC (p= 0.04). The presence of intraoperative CVC increased the risk of EB 9-fold [OR: 9.4 (95%CI: 1.288-69.712) (p= 0.027)]. The lack of preoperative prophylaxis did not increase the risk of EB [OR: 2.2 (CI: 0.383-12.669) (p= 0.3)]. The association with other variables was not significant.

Conclusions: The intraoperative presence of CVC was a risk factor of EB in our patients. Preoperative prophylaxis had no impact on the risk of EB, which in our view does not support its use. However, further studies with a larger sample size are required. Leukopenia or neutropenia at diagnosis were not associated with a greater prevalence of infection.

Objective: Acute appendicitis (AA) is the most frequent urgent surgical pathology in the pediatric population, but postoperative management is variable, with protocols minimizing variability. We present our results following the optimization of the management protocol in our institution in order to establish its efficacy in terms of number of infectious complications and optimization of resources in our environment.

Materials and methods: An observational, retrospective study of patients undergoing AA surgery from January 2018 to August 2022 was carried out. Two cohorts were compared, both before (1) and after (2) the implementation of the new protocol. They were divided according to severity in order to conduct a subgroup-based analysis -phlegmonous (PH), gangrenous (G), and perforated (P) appendicitis.

Results: 771 patients (1: 390; 2: 381) were included, with a homogeneous distribution and a median age of 9.3 ± 2.8 years. Blood tests requested prior to discharge experienced a significant reduction (PH: 3.9% vs. 0.5%; p= 0.026; G: 97.6% vs. 13.4%, p< 0.001). Days of hospital stay decreased in the PH (1.2 IQR: 0.7 vs. 1 IQR: 0.36; p< 0.001) and G (4 IQR: 1 vs. 3 IQR: 1 days; p< 0.001) subgroups. No differences in the number of abscesses were found between groups (41 vs. 43; p= 0.73), but they were noted within subgroup G (9 vs. 2; p= 0.029). A reduction in resource expenses was detected in PH and G appendicitis.

Conclusions: In our study, the most widely benefited subgroup following protocol optimization was the gangrenous appendicitis subgroup, with a significant reduction in the number of complications and the use of hospital resources.

Objective: High-pressure balloon pneumatic dilatation for the treatment of primary obstructive megaureter (POM) was initially described under cystoscopic and radiological control. However, some groups use cystoscopic control only, in an attempt to avoid the ionizing radiation associated with the procedure.

Materials and methods: A retrospective study of POM patients treated with pneumatic dilatation in our unit from 2008 to 2021 was carried out. Success rates, complications, and follow-up were compared between two groups -dilatation under cystoscopic control alone (CS) vs. dilatation under radiological control only (RX).

Results: 23 patients -9 CS and 14 RX- underwent surgery. Both groups were demographically comparable. Mean hospital stay was significantly shorter in the CS group (1 vs. 2 days; p =  0.009). Operating time was longer in the RX group (78 vs. 30 min; p =  0.001). Ureterovesical junction (UVJ) dilatation was successful in 100% of CS vs. 79% of RX cases; RR: 3.87 (0.51-26.99). Postoperative complications were similar in both groups; RR: 3.87 (0.51-26.99). Double J stent migration occurred in one case in both groups; RR: 0.64 (0.05-9.03). In the long-term, treatment success rate was higher in the CS group (100% vs. 71%); RR: 3.87 (0.51-26.99).

Conclusion: POM pneumatic dilatation under cystoscopic control alone is faster, without increasing the risk of complications. Based on our experience, we suggest ionizing radiation be removed, since we consider it to be unnecessary.

Introduction: Hostile abdomen is a surgical condition characterized by loss of space between organs and structures in the abdomen. Negative pressure therapy use has been widely described in adults; the case is not the same for pediatric patients. The goal of this study is to present short-term results of negative pressure therapy use in pediatric patients with hostile abdomen due to different etiologies.

Material and methods: Pediatric hostile abdomen patients (< 18 years) who were treated Negative pressure therapy using ABTHERA were identified and retrospectively reviewed.

Results: 7 patients were included in this study. Median age was 16 (range: 9-17 yo). 5 (71.4%) were male and 2 (28.6%) females. 3 (43%) had significant past medical/surgical history (Systemic Lupus Erythematosus, complicated appendectomy and ventriculoperitoneal-shunt). The device was set at a continuous pressure ranging from -50 to -125 mmHg. Pre and post-surgical findings were reported using Bjork's classification. Devices were replaced every 4-7 days (median 5 days). Total amount of replacements was 1-4 (median 3). 5 (71.4%) patients required invasive mechanical ventilation during use of Negative pressure therapy based on clinical status. 4 (57%) patients received enteral nutrition. 1 (14%) patient required re-intervention posterior to definitive closure due to retroperitoneal abscess development. Outcome, evaluated by (oral tolerance, bowel movement and absence of pain), was favorable in all patients.

Conclusion: Negative pressure therapy devices generate favorable results in hostile abdomen in pediatric population but further information is needed to assess pressure settings and device replacement frequency.