Minimally invasive repair of Morgagni hernia - A multicenter case series

Children may benefit from minimally invasive surgery (MIS) in the correction of Morgagni hernia (MH). The present study aims to evaluate the outcome of MIS through a multicenter study. National institutions that use MIS in the treatment of MH were included. Demographic, clinical and operative data were analyzed. Thirteen patients with MH (6 males) were operated using similar MIS technique (percutaneous stitches) at a mean age of 22.2±18.3 months. Six patients had chromosomopathies (46%), five with Down syndrome (39%). Respiratory complaints were the most common presentation (54%). Surgery lasted 95±23min. In none of the patients was the hernia sac removed; prosthesis was never used. In the immediate post-operative period, 4 patients (36%) were admitted to intensive care unit (all with Down syndrome); all patients started enteral feeds within the first 24h. With a mean follow-up of 56±16.6 months, there were two recurrences (18%) at the same institution, one of which was repaired with an absorbable suture; both with Down syndrome. The application of MIS in the MH repair is effective even in the presence of comorbidities such as Down syndrome; the latter influences the immediate postoperative recovery and possibly the recurrence rate. Removal of hernia sac does not seem necessary. Non-absorbable sutures may be more appropriate.

Thoracoscopy in the management of pediatric empyemas

INTRODUCTION

Thoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children.

MATERIAL AND METHODS

Clinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed.

RESULTS

Ninety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001).

DISCUSSION AND CONCLUSIONS

Thoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.

[Outcome of laparoscopic Heller myotomy in children]

AIM

The appropriate management of achalasia in children remains debatable. The present study aimed to evaluate the outcome of laparoscopic Heller myotomy by assessing short- and mid-term issues.

METHODS

Children submitted to surgery from 2002 to 2010 were included. Surgery was proposed after failure of endoscopic dilatations. All patients underwent esophagocardiomyotomy (Heller) plus anterior fundoplication (Dor) by laparoscopy. Demographics, presentation symptoms and perioperative details were analyzed. The outcomes were assessed both by medical records and the application of a 14 items (score 0-worst to 4-best/normal) self-evaluation questionnaire (modified GIQLI - covering only upper gastrointestinal symptoms).

RESULTS

Six patients (5 males) with a median age of 12.2 years (range: 0.8-14.2) were submitted to surgery. The presenting symptoms were: dysphagia (83.3%), weight loss (50%), vomiting (33.3%), chronic cough (33.3%), and chest pain (16.7%). All patients were operated on by laparoscopy with no conversions; there were no intra or postoperative complications. At a median follow-up of 5 years (range: 2-10) none of the patients were re-operated. Five patients have normal eating habits; the remaining case presented recurrent episodes of dysphagia requiring regular endoscopic dilatations (every 6 months). The total GIQLI presented a mean score of 49.3 (range, 45-52) representing 88.1% of the theoretical maximum. The score for frequency of dysphagia episodes was 1.6 +/- 1.4; all patients scored 3 for the grade of dysphagia.

CONCLUSIONS

Laparoscopic Heller myotomy is effective and safe for achalasia in children, offering a good and durable quality of life; although frequent, the dysphagia episodes were mild.