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

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.

Introduction: Giant omphalocele poses a conflict between eviscerated content and abdominal capacity, with associated risks such as compartment syndrome or cardiovascular compromise.

Clinical case: We present the case of a prenatally diagnosed hepato-omphalocele, without associated abnormalities. At week 37, botulinum toxin was injected in the right hemiabdomen under fetal and maternal sedation. Following Cesarean section, scheduled at week 39, injection was completed in the left hemiabdomen, and full hepatic content reduction and total amnion inversion were achieved. Definitive repair with component separation was carried out on day 8 postnatally, and the patient was discharged on day 14.

Discussion: Botulinum toxin induces muscle relaxation, which can help reintroduce the eviscerated content within the abdominal cavity. The maximum effect is achieved following two weeks, which means prenatal injection may favor early amnion inversion, thus reducing hospital stay.

Objective: To assess the outcomes of three surgical techniques in the management of simple gastroschisis.

Materials and methods: An observational, descriptive, retrospective, longitudinal study was carried out. Medical records of patients diagnosed with simple gastroschisis and treated with different surgical techniques -Simil-Exit, primary closure, and deferred closure- were reviewed.

Results: 38 gastroschisis patients undergoing either the Simil-Exit (n= 10), the primary closure (n= 11), or the deferred closure (n= 17) techniques were analyzed. The Simil-Exit technique involved a shorter operating time than primary closure and deferred closure. Both Simil-Exit and primary closure patients required a shorter mechanical ventilation time, fewer days of parenteral nutrition, shorter time to oral feeding initiation, and a shorter hospital stay than deferred closure patients. The deferred closure technique had more frequent complications, such as sepsis.

Conclusions: The Simil-Exit and the primary closure techniques demonstrated favorable outcomes in patients with simple gastroschisis. In addition, the former involved shorter operating times, it required less exposure of the small bowel loops to the environment, it was easily reproducible, and it provided a better cosmetic result.

Introduction: Chordoma is a rare, slow-growing notochordal neoplasm typical of adults. Less than 5% of the cases occur in children, where they are located at the skull base. Treatment involves surgical resection with or without radiotherapy.

Clinical case: 14-month-old patient with a left dorsal lumbar mass, pain, and limited mobility in the lower limbs. MRI showed a left paravertebral mass infiltrating the spinal canal (T11-L1), in contact with the parietal pleura, along with abdominal extension. Chordoma diagnosis was established based on percutaneous biopsy. Full resection without safety margins was carried out using the posterior approach. One month later, tumor recurrence caused hemothorax, pleural infiltration, and rib infiltration. Two chemotherapy cycles were administered, with a good response. Reintervention was successfully conducted one month later. After 9 months, the patient is free from disease, under chemotherapy treatment and proton therapy.

Discussion: Although unusual, chordoma is included within the differential diagnosis of retroperitoneal masses. Prognosis depends on full resection.

Introduction: Robotic surgery has revolutionized surgical practice globally since the first Da Vinci device was launched in 2000. Adoption in Spain has been more moderate than in other countries, especially in the field of pediatric surgery, which represents less than 0.5% of all robotic procedures. This paper features a review of the scientific literature on the pediatric robot-assisted surgeries published in Spain. The objective was to provide a full overview of the cases documented in Spain and to highlight opportunity areas for the growth of this technology.

Materials and methods: A comprehensive search of scientific papers on PubMed, Scielo, and Google Scholar databases was carried out. Search terms included "robotic surgery," "pediatric," "Spain," "robot-assisted surgery," and "pediatric surgery." Specialists in the field and the Da Vinci robot distributor in Spain were also contacted to collect additional scientific evidence.

Results: Of the 87 papers identified, 6 met inclusion criteria. The studies reviewed document the experience with pediatric robotic surgery in three Spanish hospitals -Vall d'Hebrón Hospital, San Carlos Clinical Hospital, and Reina Sofía Hospital. Clinical results were mostly positive, with low complication rates and good postoperative recoveries. However, some challenges, such as long operating times, a certain difficulty in robotic arm placement, and the high cost of this device, were also pointed out.

Conclusions: Pediatric robotic surgery in Spain is in an early developmental stage, with a limited number of publications, and experience that is available in very few institutions. Further research is required to reinforce scientific evidence and promote investment in this technology.

Introduction: Pain control following Nuss thoracoplasty remains a challenge. Cryoanalgesia of the intercostal nerves has been demonstrated to reduce postoperative pain in these patients. The objective of this study was to understand how and how widely cryoanalgesia is used in pediatric patients undergoing funnel chest surgery in Spain.

Materials and methods: Nationwide online submission of an author-designed survey.

Results: 18 hospitals replied to the survey. 9 (50%) said they do not use cryoanalgesia, primarily as a result of difficulties in accessing this technique, whereas the other 9 said they do employ it. In most institutions, cryoanalgesia is percutaneous and ultrasound-guided, and it is conducted 1-3 days before surgery (77.8%). The associated use of other analgesic modalities varies widely, including various combinations of intravenous opioid-based PCA (77.8%), epidural catheter (66.7%), oral pregabalin (66.7%), and erector spinae plane block (22.2%). In the institutions where cryoanalgesia is used, mean hospital stay is 4.7 days. Most surgeons believe cryoanalgesia significantly reduces pain in the long-term (88.9%), and only partially in the immediate postoperative period (66.7%).

Conclusions: The use of cryoanalgesia for pain control following Nuss thoracoplasty is an emergent technique. In the Spanish institutions where this technique is used, varying protocols with different associated analgesic modalities can be found.