Impact of digestive-surgical cross-disciplinary management in patients with esophageal atresia

OBJECTIVE

The objective of this study was to analyze whether patients undergoing esophageal atresia (EA) surgery benefit from a cross-disciplinary follow-up program, based on current clinical guidelines, implemented in our institution.

MATERIALS AND METHODS

An observational, analytical, retrospective study of patients undergoing EA surgery from 2012 to 2022 was carried out. The results of a joint pediatric surgery and gastroenterology consultation program -which was implemented in 2018 and applies a protocol based on the new ESPGHAN-NASPGHAN guidelines- were analyzed. Patients were divided according to whether they had been treated before or after 2018. Quantitative variables -follow-up losses, anti-reflux treatment initiation and duration, and enteral nutrition initiation- and qualitative variables -prevalence of gastroesophageal reflux, anti-reflux surgery, respiratory infections, anastomotic stenosis, re-fistulizations, dysphagia, impaction episodes, need for gastrostomy, and endoscopic results- were compared.

RESULTS

38 patients were included. 63.2% had gastroesophageal reflux. 97.4% received anti-reflux treatment in the first year of life, with treatment being subsequently discontinued in 47.4%. Discontinuation time decreased by a mean of 24 months following program implementation (p< 0.05). A 4.6-fold increase in the frequency of pH-metries was noted following program implementation. The protocol standardized endoscopies in asymptomatic patients when they turn 5 and 10 years old. 25 endoscopies with biopsy were carried out after 2018, with histological disorders being detected in 28% of them. The number of follow-up losses significantly decreased following protocol implementation (p< 0.05).

CONCLUSIONS

Digestive-surgical cross-disciplinary follow-up of EA patients has a positive impact on patient progression. Applying the guidelines helps optimize treatment and early diagnosis of complications.

Pediatric surgical activity during the SARS-CoV-2 pandemic: experience at a tertiary hospital

OBJECTIVES

The primary objective was to describe the characteristics and demographics of the surgical procedures carried out at a tertiary hospital during the SARS-CoV-2 pandemic. The secondary objective was to study the impact of the pandemic on the acute appendicitis cases treated at our healthcare facility and to compare them with a pre- SARS-CoV-2 period.

MATERIAL AND METHODS

A retrospective study of all patients undergoing surgery at the pediatric surgery department in the pandemic period, from the beginning of the state of emergency in Spain until the first restrictions were removed, was conducted.

RESULTS

A total of 61 patients underwent surgery in 58 days vs. 406 patients in the same 2019 period (p < 0.00001). 59.01% of surgeries were urgent. 5.1% of patients had a positive SARS-CoV-2 diagnostic test. 30 different procedures were carried out, with appendectomy being the most frequent one (n = 13, 19.6% of patients). 61.5% of appendicitis cases were complicated vs. 42.4% in the non-COVID period (p = 0.17). Surgical approach was open in 46.1% of patients vs. 6.1% in the non-COVID period (p = 0.004). No statistically significant differences were found in terms of complication rate or hospital stay.

CONCLUSIONS

During the SARS-CoV-2 pandemic, a significant decrease in the number of daily procedures was noted, with more than half being urgent. Appendicular pathologies were in a more advanced stage than usual, with a clear trend towards open surgery vs. laparoscopy.

Thyroid surgery in pediatric patients: causes and results

OBJECTIVE

Even though thyroid surgery is rare in pediatric patients, frequency has increased in the last years. The objective of this study was to analyze the causes and results of these procedures in a pediatric surgical facility.

PATIENTS AND METHODS

Retrospective study including all patients requiring thyroid surgery in our department from 2000 to 2019. Demographic data, diagnostic data, associated pathology, type of surgical procedure, pathological results, and intraoperative and postoperative complications were recorded.

RESULTS

47 patients with a mean age of 8.9 ± 3.9 years at surgery were included. The most frequent diagnosis was MEN syndrome (n = 30, 29 MEN 2A and 1 MEN 2B), followed by thyroid papillary carcinoma (n = 5), follicular adenoma (n = 5), multinodular goiter (n = 4), follicular carcinoma (n = 1), thyroglossal duct papillary carcinoma (n = 1), and Graves-Basedow syndrome (n = 1). 38 total thyroidectomies (73.7% of which were prophylactic), 3 double hemithyroidectomies, 5 hemithyroidectomies, and 5 lymphadenectomies were performed. No intraoperative complications or recurrent laryngeal nerve lesions were noted. Mean postoperative hospital stay was 1.3 ± 0.6 days. 7 patients had transitory asymptomatic hypoparathyroidism, and 1 patient had persistent symptomatic hypoparathyroidism. Pathological results of prophylactic thyroidectomies were: 18 C cell hyperplasias, 7 microcarcinomas, and 3 cases without histopathological disorders.

CONCLUSIONS

Thyroid surgery in pediatric patients is safe if performed by specialized personnel. Even though it remains rare, frequency has increased in the last years.

Bronchoalveolar lavage usefulness in the pediatric population

OBJECTIVE

To analyze bronchoalveolar lavage diagnostic effectiveness and impact on therapeutic management in pediatric patients.

MATERIAL AND METHODS

Retrospective study of patients undergoing bronchoalveolar lavage at the pediatric surgery department from 2009 to 2019. The sample was divided into two groups: hemato-oncological patients and non-hemato-oncological patients. Demographic variables, bronchoalveolar lavage result, and subsequent therapeutic attitude were collected.

RESULTS

45 bronchoalveolar lavages were carried out in 38 patients. The hemato-oncological group consisted of 25 bronchoalveolar lavages. Patient mean age was 9.99 ± 2.34 years. 80% of patients had received anti-infective treatment prior to bronchoalveolar lavage. Bronchoalveolar lavage culture was positive in 52% of cases. Bronchoalveolar lavage results translated into therapeutic management change in 24% of cases (6/25). 3 postoperative complications were recorded, all mild. In the non-hemato-oncological group (n = 20), mean age was 6.70 ± 5.17 years. Bronchoalveolar lavage was positive in 25% of cases, and translated into management change in 5% of patients. Complication rate in this group was 30%. 2 patients required mechanical ventilation.

CONCLUSIONS

According to our results, bronchoalveolar lavage in hemato-oncological patients helps achieve microbiological diagnosis in infectious respiratory conditions and is relatively well-tolerated. In non-hemato-oncological patients, diagnostic and therapeutic usefulness is low, and complication rate is not negligible. The risk-benefit balance should be individually considered in each patient.

Measuring esophageal anastomotic stricture index as a predictor of dilatation following esophageal atresia surgical repair

INTRODUCTION

Anastomotic stricture is the most common complication following esophageal atresia (EA) surgical repair. The objective of this study was to evaluate Anastomotic Stricture Index (ASI: relationship between pouch and stricture diameters in the postoperative esophagram) as a predictor of the need for esophageal dilatation.

METHODS

A retrospective review of all patients undergoing EA repair in our healthcare facility from 2009 to 2017 was designed. Proximal pouch ASI (proximal ASI) and distal pouch ASI (distal ASI) in the first and second postoperative esophagram were calculated, and correlation with the number of esophageal dilatations required was studied. For statistical analysis purposes, Spearman's correlation test and ROC curves were used.

RESULTS

Of the 31 patients included, 21 (67.7%) required esophageal dilatation, and 11 (35.5%) required 3 or more dilatations. The relationship between ASIs in the first esophagram and the need for esophageal dilatation was not statistically significant (p >0.05). The relationship between proximal ASI (RHO = 0.84, p <0.05) and the number of dilatations in the second esophagram was statistically significant. None of the patients with <0.55 proximal ASI required dilatation; patients with 0.55-0.79 proximal ASI required less than 3 dilatations; and patients with >0.79 proximal ASI had a high risk of requiring 3 or more dilatations.

CONCLUSION

According to our study, measuring ASI in the second esophagram proves useful in predicting EA patients' postoperative management, especially when it comes to identifying patients with lower risk of undergoing multiple dilatations.

[More than three hours, less than three years. Safety of anesthetic procedures in children under three years, subject to surgeries of more than three hours]

The Food and Drug Administration (USA) warning (December 2016) on the safety of general anesthesia and sedation in patients younger that 3 years and pregnant women has raised many questions about the attitude that should be taken by professionals involved in the treatment of these patients. In view of this situation, the following Medical Scientific Societies: SEDAR, SECP, SECIP and SENeo have constituted a working group to analyze and clarify the safety of these techniques. In the present article, we conclude that at present both general anesthesia and deep sedation should continue to be considered safe techniques because there is no sufficient opposing evidence in clinical studies with humans. Despite this, we should not ignore the problem which must be followed carefully mainly in patients under three years of age undergoing anesthetic procedures longer than three hours or prolonged sedation in Neonatal or Pediatric Intensive Care Units.

[When should a patient be referred to the pediatric surgeon?]

INTRODUCTION

An incorrect transfer of patients to paediatric surgery clinic results in clinic saturation and both patient and medical staff discomfort. As a consequence the quality of medical care is deteriorated.

AIM

1) To evaluate the transfer of new patients to paediatric surgery clinic from primary paediatric care considering the medical diagnosis and the surgical calendar, looking for the most common mistakes. 2) To analyze the inconvenience of a wrong indication for both our patients and the medical staff. 3) To propose new measures to decrease the rate of patients incorrectly transferred.

MATERIAL AND METHOD

An observational retrospective study was performed based on medical records of new patients evaluated in paediatric surgery clinic between september 2010 and january 2012. Age, address, diagnosis, transfer indication and referring centre were collected.

RESULTS

Two thousand four hundred thirty medical records were reviewed from new patients finding an incorrect transfer in 44.28% of them (2.37 children/day). From these cases wrong transfer was related to surgical calendar in 18.59% and wrong diagnosis in 81.41% of them. Most common mistakes due to wrong diagnosis were Phimosis (91.45% n= 113) and Cryptorquidism (85.29% n = 122); mistakes related to surgical calendar were Umbilical Hernia (88.46%), Hypospadias (72.22% n= 31) and Hydrocele (70.83% n = 12). Mean distance of transfer for patients wrongly referred outside the metropolitan area was 35.92 km (Range: 7.1-129).

CONCLUSIONS

We have detected major mistakes in patient transfer from primary paediatric care. The knowledge of surgical calendar and accurate diagnosis should avoid these problems. These mistakes result in deterioration of medical care quality, patient discomfort and clinic saturation. It is necessary to propose and develop measures that improve the knowledge of surgical calendar and to make more accurate surgical diagnosis in primary paediatric care.

[Bronchoplastic surgery: tumorectomy in principal left bronchial tube in a 5-month old child]

INTRODUCTION

Resection of bronchial tumors usually needs resection of the lung parenchyma ventilated by the ill bronchus. Surgery over a developing child must preserve the biggest amount of lung parenchyma as possible. We show a complete resection of a benign tumor from the left main-stem bronchus, without pneumonectomy.

MATERIALS AND METHODS

Case report

RESULTS

A 5 month girl presented with left hypoventilation. No significant previous dates. After bronchoscopy (with negative biopsy), chest radiograph and CT, she was diagnosed of a tumor in the mainstem left bronchus (20 x 15 mm) without metastatic extension. A sleeve resection of the tumor, with carinal reconstruction was performed. It was done under unipulmonary ventilation, with selective bronchial intubation. The patient was extubated in the operating room and the hospital stay was of 5 days. Follow up bronchoscopies shows no anastomotic stricture neither leakage. The patient is doing well 2 years after surgery.

CONCLUSIONS

With this report and others in literature we can say that is possible to resect bronchial tumors in infancy without parenchymal resections.

[Comparative analysis between the Seldinger technique vs. open dissection in the implantation of intravenous reservoirs]

OBJECTIVE

To analyze advantages and disadvantages between Seldinger's technique (ST) and surgical dissection (SD) on intravenous port-a-caths comparing surgical parameters as time and complications.

MATERIAL AND METHOD

An analytic retrospective study involving historic cohorts was realized, comparing our surgical experience on port-a-cath implantation with Seldinger technique or surgical dissection. Statistical analysis was made reflecting clinical and surgical parameters, such as surgical time length and intra/postoperative complications.

RESULTS

193 Port-a-caths were analyzed (119 SD, 74 ST), mainly placed for chemotherapy treatment (83.41%). Surgical time length expended at single procedures was 72.85 +/- 29.35 minutes for SD and 62.83 +/- 20.08 minutes for ST (p < 0.05). There were none operator-dependent differences. Statistically significant differences were not found between the two cohort's populations, neither at complications percentages. Greater-sized port-a-caths presented a higher average of skin necrosis (p > 0.05) however, lower-sized port-a-caths showed a higher average of infection (16% upon 7.7% p > 0.05). Both ST (51.67 vs. 98.14 min) and SD (78.56 vs. 123.61 min) showed lower surgical time length at left venous accesses (d = 171 vs. i = 19). Average in days for the extraction of port-a-caths with regard to complications was 121 days.

CONCLUSION

Seldinger technique reduced the definitive lost of surgical dissected venous accesses, being possible further utilization of the same vein for subsequent port-a-caths. Seldinger technique reduces surgical time length without increasing complication's rate. Left venous access does not imply higher surgical time length. Complications may be related with port-a-cath's size.

[Perinatal diagnosis and management of epignathus]

INTRODUCTION

After the diagnosis and treatment by EXIT procedure of a case of epignathus in our centre, we have reviewed the management of this condition.

MATERIAL AND METHODS

Systematic review of the bibliography in Medline and our case experience. Search terms: "oral teraoma" OR Epignathus; Limits for age (Newborn) and languages (English, Spanish, Italian and portugese) (57 articles) and without limits (121). We select articles cases reports about oropharyngeal teratomas including diagnosis and/or treatment, specially those with polyhidramnios and/or respiratoy distress at birth. Articles before 1990 were refused.

RESULTS

Epignathus is defined as a teratoma that occupies the lumen of the craniopharyngeal canal causing an obstructive polyhydramnios. This is a potential cause of death due to upper airway obstruction at birth. Cardiac function can be compromised due to its size. No other lethal conditions are normally associated. Prenatal diagnosis and the strategy of the perinatal treatment seem to improve the prognosis of this condition.

DISCUSSION

Consensus exit about that prenatal diagnosis is the key to avoid the neonatal respiratory distress. Formo our experience and from others it is clearly defined that the proper treatment is the prevention of the preterm labour and delivery by EXIT procedure, in order to have the neonate airway control under foetal-placental circulation.

CONCLUSIONS

The most frequent associated anomalies with epignathus are feasible to surgical correction. The prognosis of giant epignathus seems to improve with a proper prenatal diagnosis (US and MRI) and an adequate strategy of the airway management. With EXIT procedure, a potential life-threatening emergency can be managed like an elective procedure, improving the prognosis of this children.

[Parapneumonic effussion. A review of 33 cases over 6 years]

The incidence of empyema thoracis in children seems to be increasing. The objective [corrected] of this study is to propose a rational initial treatment of parapneumonic effusions in order to reduce hospital stay and late-stage empyema complications. Medical records of 33 children presenting parapneumonic effusions who required any surgical therapy between 1997 and 2002 were reviewed. They were grouped as (I) successful management with chest tube, (II) successful management with intrapleural instillation of urokinase and (III) successful surgical treatment: (IIIa) thoracoscopy or (IIIb) thoracotomy.

CONCLUSION

Early sonographic evaluation of parapneumonic effusions is usefull to evaluate the severity of disease and the need for surgical intervention. Thoracoscopic-assisted surgery is an effective treatment for pediatric early-stage empyema. Thoracotomy is indicated for most children with established empyema.

[Events related with injury severity in pediatric multiple trauma]

AIMS

Epidemiological analysis of main factors affecting multiple trauma in children in our environment.

METHODS

We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant.

RESULTS

Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability.

CONCLUSIONS

Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

[Impact of formation programs in initial management of injured children]

INTRODUCTION

In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient.

MATERIAL AND METHODS

We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p < 0.05.

RESULTS

All paramethers analyzed were better in group II than in group I (p < 0.05).

CONCLUSIONS

The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.

[Hemodynamic changes during laparoscopic surgery. Preliminary study]

The haemodynamic changes produced by laparoscopic surgery in children have been evaluated. A transesophageal echocardiographic study on 13 patients (7 males and 6 females, 10.8 +/- 2.7 years old) has been performed before, during and after peritoneal CO2 gas insufflation. A change on the Doppler waves pattern of the infradiaphragmatic veins along with an increase in blood flow velocity were observed. Pulmonary veins suffered minimal changes showing an increase on either the systolic pressure and on atrial contraction. Diastolic retrograde flow in aorta reflected an increase in peripheral vascular resistance. Cardiac output increased minimally. All haemodynamic changes returned to basal after gas peritoneal desufflation. These data show that laparoscopic surgery could produce important cardiac derangements in children with ventricular dysfunction or in patients presenting left ventricular outlet obstruction. In these patients laparoscopic surgery might be precluded.

[Tissue expansion in the reconstruction of post-burn lesions in childhood]

Tissue expansion has gained increased acceptance in postburn reconstruction. In this study, the clinical outcome in 17 paediatric burn patients is outlined. A total of 46 tissue expanders were inserted for the reconstruction of postburn scalp alopecia (n = 11) and burn scars (n = 6). The average size of soft tissue defect was 124 cm2. Mean followup was 19 months. The overall outcome in most cases was excellent, however, complications were common (37%) and included infection, exposure, port loss, and partial flap necrosis. Five patients in the scalp reconstruction group required transfusion (45%). Tissue expansion in paediatric burn reconstruction is a useful technique which may yield superb results, however, careful surgical planning is essential to avoid complications.

[Post-traumatic cholelithiasis]

A 5 year old patient, without any lithogenic antecedent, suffered a trauma, resulting in a shrunken fracture of the left parietal bone, and a splenic parenchymal hematoma. A hemoperitoneum developed at the 3rd postoperation day, with an overall blood loss of 15% of the total blood volume. At the 6th day a well formed biliary calculi was detected in the gallbladder. As the patient remain asymptomatic related to his cholelithiasis, an ultrasound follow-up was instituted. At 3 month postinjury all biliary stones dissolved completely. In this report, the etiopathogenic factors responsible of stone formation in the biliary tree, and current therapeutic recommendations are reviewed.

[Nuclear magnetic resonance of anorectal malformations and persistent postoperative fecal incontinence]

We review our experience with Magnetic Resonance Imaging (MRI) in the evaluation of 6 patients showing anorectal malformation, and 4 more with persistent postoperative fecal incontinence. Preoperative sagittal, axial and coronal planes were studied with special consideration to the pelvic and vertebral structures. The excellent resolution of MRI allowed accurate identification of the pelvic musculature in all patients, including those with bizarre sacral abnormalities. MRI revealed structural anomalies not detected previously, such as teathering cord, intraspinal lipoma, presacral mass and renal malformation. In our institution, MRI has replaced the CT scan in the study of patients suffering of persistent fecal incontinence. In non operated on cases of anorectal malformations, MRI determines with extraordinary accuracy the location of the rectal atretic pouch, the actual pelvic muscular quality, and the detection of previously unsuspected associated anomalies.

[Pyknodysostosis: extreme cause of sleep apnea]

We describe a twentieth month old infant who had a pycnodysostosis syndrome. This malformation shows a loss of the normal mandible angle with generalized bone hyperdensification. The first produced and airway obstruction, with special relevance during sleeping hours. A polysomnography revealed an obstructive sleep apnea syndrome. The respiratory picture deteriorated with worsening of the airway obstruction, hypoxemia and finally pulmonary hypertension and cor pulmonale. A tracheostomy was performed, with resolution of the sleep apnea and pulmonary hypertension. The etiology, pathophysiologic consequences and surgical treatment of obstructive sleep apnea syndrome is reviewed.

[A case of total intestinal aganglionosis. 2 years of survival]

A two-year-old male is presented. Small bowel aganglionosis was proved to extend to 3 cm below ligament of Treitz. Gastrostomy and ileostomy was done. He received his caloric intake by cyclic home parenteral nutrition trough implantable venous system. At eighteen months of age, intestinal transplantation was refused and reoperation was done. The child underwent Ziegler's miotomymiectomy on 60 cm of aganglionic jejunum. Now at twenty seven months of age he receives cyclic parenteral nutrition, and enteral feedings are being increased slowly. The weight/height was at 91 per 100 standard, intestinal motility appears much better on contrast study and he is developmentally a normal child.

[The early diagnosis of intestinal ischemia by gammagraphic study]

Intestinal wall necrosis without perforation was produced in six dogs. Another group of three dogs served as a control. The histologic findings, the degree of ischemia and scintigraphic images obtained after the infusions of autologous white blood cells labelled with indium-111 oxine were correlated. Positive scans were obtained in all the dogs with proven intestinal ischemia. Negative scans appeared in the dogs without ischemic insult and a false-positive scan were observed in a control dog with diarrhea.

[Sepsis in children using venous implants with reservoir]

Sepsis is a serious situation in patients with chronic central venous access. The infections complications presented with totally implanted reservoirs are studied in this paper. Twenty five venous systems for chemotherapy, total parenteral nutrition, specific drugs and blood drawing, were placed in 24 patients ranging in age from three months to sixteen years. Catheter related sepsis was defined as simultaneous positive blood cultures drawn through the reservoir and peripheral vein. Five children (20 per 100) had septicemia with candida albicans (3), staphylococcus aureus (1) and staphylococcus epidermidis (1). Four systems was removed after unsuccessful antimicrobial therapy. Three symptomatic patients were studied by echocardiography, one of them showed thrombosis in superior vena cava and right atrium, this child underwent an open atriotomy. These data suggest that removal of implantable venous system is required for successful treatment in patients with catheter related sepsis.

Papillary cystic tumor of the pancreas

A 10-year-old girl had fever, abdominal pain and a palpable mass at the left hypochondrium. She was found to have a pancreatic cystic tumour that was biopsied and removed by coeliotomy. The pathologic diagnosis was papillary cystic tumour of the pancreas with chronic pancreatitis. No pathological lesion was found elsewhere. 2 years later she is asymptomatic and without recurrence.