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

Introduction: Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) has a low malignancy potential. First acknowledged by the WHO in 2017, this tumor is rare in the pediatric population, with less than 25 cases reported. Accurate diagnosis is key to avoid overtreatment and complications.

Clinical observation: Two cases of adolescents with solid thyroid nodules assessed by fine-needle aspiration biopsy are presented. Hemithyroidectomy was decided upon. Both surgical specimens were reported as NIFTP. Both cases were presented before a cross-disciplinary board, and since malignancy potential was low, treatment was regarded as completed.

Discussion: NIFTP identification is key to avoid unnecessary treatments such as total thyroidectomy or iodine therapy, which may bring about serious consequences in children. A high level of diagnostic suspicion and a cross-disciplinary approach are required to optimize management and clinical results in these patients.

Introduction: Ewing sarcoma is a rare malignant tumor with an incidence of 3 cases per 1 million inhabitants annually. Cross-disciplinary management is key to improve survival rates. The role played by intraoperative radiotherapy in terms of treatment is still to be defined.

Material and methods: A retrospective study of pediatric patients (up to 16 years of age) with chest wall Ewing sarcoma undergoing tumor resection surgery, intraoperative radiotherapy, and chest wall reconstruction in our institution from 2011 to 2024 was carried out. Variables such as age at surgery, sex, neoadjuvant treatment, resection type, characteristics of intraoperative radiotherapy, reconstruction type, complications, local control rate, relapses, survival, and reconstruction's functional result were collected.

Results: 8 patients were included. Mean age at diagnosis was 12.5 years. Full tumor mass removal with free margins (R0) was achieved in 100% of the cases. Reconstructive techniques with flexible patches, titanium plates, and muscle flaps were used. None of the flaps was lost. Overall survival was 87.5%, with a mean follow-up period of 6 years. 3- and 5-year overall survival rates were 100% and 80%, respectively. Local control of the disease was achieved in 100% of the cases.

Conclusions: This paper discusses the role of intraoperative radiotherapy as a good treatment alternative to achieve the local control of Ewing sarcoma associated with large surgical resections.

Introduction: Pulmonary interstitial emphysema is a severe rare complication associated with mechanical ventilation in pre-term patients. It induces alterations both in ventilation and pulmonary perfusion, and it may cause progressive overdistension of the side involved and atelectasis of the contralateral lung. Management is uneasy and requires changing ventilation strategies, with invasive procedures such as blockage and selective pulmonary ventilation being potentially necessary.

Clinical case: Premature female patient born at gestation week 26+0, with an initially good clinical progression and baseline chest X-rays showing no signs of congenital pulmonary injury. On day 20 of life, progressive respiratory deterioration was noted. In the series X-rays and chest CT-scan, a right-sided pulmonary interstitial emphysema with mediastinal displacement and left-sided pulmonary atelectasis, associated with hemodynamic and respiratory instability, was observed. On day 26 of life, in light of the poor clinical progression and the immediate threat of death, decision was made to place a right-sided bronchial blocker with a 3x20 mm angioplasty balloon, after the bronchus had been measured through CT-scan. Following placement, respiratory and ventilation parameters improved immediately. The device was kept inflated for 3 days. 10 days after removing the bronchial blocker, the patient was successfully extubated, and she was discharged after 100 days in hospital, with no respiratory symptoms, and the pre-discharge CT-scan showing no signs of emphysema. After 50 months of follow-up, the patient remains asymptomatic from a respiratory standpoint, and psychomotor development is normal.

Discussion: Selective angioplasty balloon pulmonary blockage has been supported by scientific evidence in extremely premature patients with acquired interstitial emphysema associated with compromised ventilation and atelectasis of the contralateral lung. In our case, it helped save the patient's life with not sequelae being caused.

Objective: To assess the efficacy and safety of conservative management with interval appendectomy vs. baseline surgery in the treatment of appendiceal phlegmon.

Material and methods: A retrospective study of the 76 phlegmons treated from July 2016 to June 2024 was carried out. Two treatment groups were created -the baseline surgery (G1: 46 children) group and the conservative with interval appendectomy (G2: 30 children) group. Clinical and progression characteristics of both groups were collected and compared.

Results: No significant differences were found in terms of age, progression time, presence of appendicolith, or mean hospital stay. The number of intra-abdominal collections at diagnosis was greater in G2 (21.7% vs. 56.6%; p< 0.05), and the percentage of complications was significantly higher in G1 (54.34% vs. 20%; p< 0.002). In G2, 3 collection drainage procedures were carried out, and 4 children underwent surgery in an acute stage as a result of treatment failure. Following discharge, 2 patients from G2 underwent emergency surgery, 4 refused surgery, and 20 underwent surgery after 184 ± 55 days. Of the latter, 2 had complications. 89.47% of the appendices removed had histological disorders.

Conclusions: Conservative treatment of appendiceal phlegmon is safe and effective. It significantly reduces morbidity, and it is not contraindicated by age, presence of appendicolith, or intra-abdominal collections. However, large collection drainage procedures may be required. We believe interval appendectomy is indicated in a period of 3-6 months.

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.

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.

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.