Beyond image defined risk factors (IDRFs): a delphi survey highlighting definition of the surgical complexity index (SCI) in neuroblastoma.

PURPOSE: Preoperative evaluation of Image Defined Risk Factors (IDRFs) in neuroblastoma (NB) is crucial for determining suitability for upfront resection or tumor biopsy. IDRFs do not all carry the same weighting in predicting tumor complexity and surgical risk. In this study we aimed to assess and categorize a surgical complexity (Surgical Complexity Index, SCI) in NB resection. METHODS: A panel of 15 surgeons was involved in an electronic Delphi consensus survey to identify and score a set of shared items predictive and/or indicative of surgical complexity, including the number of preoperative IDRFs. A shared agreement included the achievement of at least 75% consensus focused on a single or two close risk categories. RESULTS: After 3 Delphi rounds, agreement was established on 25/27 items (92.6%). A severity score was established for each item ranging from 0 to 3 with an overall SCI range varying from a minimum score of zero to a maximum score of 29 points for any given patient. CONCLUSIONS: A consensus on a SCI to stratify the risks related to neuroblastoma tumor resection was established by the panel experts. This index will now be deployed to critically assign a better severity score to IDRFs involved in NB surgery.

Ovarian transposition as a minimally invasive fertility preservation technique: ten years of experience in a pediatric center. / La transposición ovárica como técnica de preservación de la fertilidad en edad pediátrica: 10 años de experiencia en un centro de tercer nivel.

INTRODUCTION: Ovarian transposition is a surgical procedure allowing gonadal mobilization from a radiation spotlight to a safer, radiation therapy-free place in patients receiving abdominal or pelvic radiation therapy. And these patients can be managed using minimally invasive surgery. Although some authors have reported good results in fertility preservation with this technique, there are no long-term studies in the pediatric population. We present our results with this procedure in our oncological patients from the last decade. MATERIAL AND METHODS: Retrospective review of medical reports of patients who underwent laparoscopic ovarian transposition in our pediatric oncological surgery unit from 2008 to 2018. The technique varied depending on age, irradiation zone, and concomitant oncological resections. RESULTS: A total of 21 ovarian transpositions were successfully performed in 13 patients. Eight were bilateral, four were left and only one was right. An ovarian cortex cryopreservation was simultaneously carried out in all patients. Eleven procedures were completed laparoscopically, and the suspensory ovarian ligament was divided in sixteen cases. The Fallopian tube was divided in one case, and a simple ovarian transposition was conducted in five cases. Mean hospital stay was 2.4 days, and no complications in the immediate postoperative period were noted. CONCLUSION: Ovarian transposition is a feasible, safe technique. These patients require an extended follow-up to assess ovarian function after oncological treatment.

INTRODUCCION: La transposición ovárica es una técnica quirúrgica que permite alejar los ovarios de la zona de irradiación en pacientes que van a recibir radioterapia abdominal o pélvica. Se han descrito buenas tasas de conservación de función. Sin embargo, no existen estudios en pacientes pediátricos. Presentamos nuestra serie de pacientes intervenidas en nuestro centro. MATERIAL Y METODOS: Estudio retrospectivo de pacientes a las que se le realizó transposición ovárica en nuestra unidad de cirugía oncológica pediátrica entre los años 2008 y 2018. La técnica empleada dependió de la edad, la zona de la irradiación y de la asociación o no con la cirugía del tumor primario. RESULTADOS: Durante el periodo de estudio se realizaron un total de 21 transposiciones ováricas en 13 pacientes (8 bilaterales, 4 izquierdas y 1 derecha). En todos los casos se realizó criopreservación de corteza ovárica dentro del programa de preservación de fertilidad. Once de las 13 intervenciones fueron por laparoscopia, seccionándose el ligamento tubo-ovárico en 16 unidades y en 5 se realizó transposición ovárica simple. La estancia hospitalaria media fue de 2,4 días sin registrarse ninguna complicación en el postoperatorio. Actualmente 9 pacientes continúan seguimiento en sus unidades de oncología pediátrica de referencia, sin haberse notificado ninguna complicación. CONCLUSION: La transposición ovárica es una técnica segura y reproducible. Estas pacientes requieren un seguimiento prolongado para conocer el estado de los ovarios tras el tratamiento oncológico.

[Benefits of epidural analgesia in major neonatal surgery]. / Ventajas de la analgesia epidural en cirugía mayor neonatal.

The aim of this paper is to describe and evaluate the benefits of epidural anesthesia in major surgery neonatal. We have performed a matched case-control (2:1) study of patients undergoing neonatal major surgery (NMSs) who received intra-and postoperative epidural anesthesia (EA) and controls with conventional general anesthesia. The matching criteria were age, weight and baseline pathology. EA was administered by caudal puncture and epidural catheter placed with ultrasound support. Levobupivacaine was selected as anesthetic drug. The time to extubation, intestinal transit time, type of analgesia and complications were studied. This study is based on 11 cases (2 esophageal atresia, 2 diaphragmatic hernias, 1 necrotizing enterocolitis, 3 intestinal atresia, 2 anorectal malformation and 1 bladder exstrophy) and 22 controls. We observed statistically significant differences in time to extubation (95% CI OR 12 1.99 to 72.35; Chi2 p = 0.004, Mann U Whytney p = 0.013) and intestinal transit time (Mann Whitney U p < 0.001, 100 Or, 95% CI 8.06-1 239; Chi2 p < 0.0001). There were no complications from epidural analgesia. Therefore we believe that the intra-and postoperative EA helps improve postoperative management in neonates and should be preferred in centers where this technique is available.

[Estimation of the risk of upper digestive tract bleeding in patients with portal cavernomatosis]. / Estimación del riesgo de hemorragia digestiva alta en pacientes con cavernomatosis portal.

PURPOSE: The aim of this study is to find out the risk of upper gastrointestinal bleeding (UGB) after the diagnosis of portal cavernoma in children, and to investigate several potential risk factors. MATERIAL AND METHODS: We analyzed retrospectively 13 cases of portal cavernoma and estimated the risk of UGB with the Kaplan-Meier survival analysis. We calculated the incidence rate of the sample and the number of haemorrhages per year for each patient individually. From the moment of the diagnosis various parameters were recorded: age, platelets, leukocytes, hemoblobin, hematocrit, prothrombin time and number of bleedings. The relation between these parameters and the risk of bleeding was assessed with the Cox analysis. RESULTS: The patients were followed for a median period of 7.1 years. 10 patients (77%) presented at least 1 episode of UGB after the diagnosis. The median survival time until the first haemorrhage was 314 days. After the diagnosis the incidence rate of the sample was 0.43 episodes of upper gastrointestinal bleeding per person-year. The number of individual bleedings per person had a range of 0-2.2 episodes per year. CONCLUSIONS: There is very few data about the risk of bleeding in children with portal cavernoma. In our sample, we found out an incidence rate of 0.43 and a median survival time of 314 days until the first episode of bleeding after the diagnosis, but we were not able to find a statistically significant association between the studied variables and the risk of bleeding.

[Results of the use of laparoscopic anti-reflux procedure for the prevention of episodes of apnea, bradycardia and desaturation]. / Resultados de la utilización de antirreflujo laparoscópico para la prevención de los episodios de apnea, bradicardia y desaturación.

In 1986 the National Institutes of Health Consensus Developement Conference on Infantile Apnea and Home Monitoring defined the Apparent Life Threatening Events (ALTEs) as those frightening episodes for the observer which are determined by a combination of apnea (central or obstructive), changes in colour (cianosis, congestive pallor) and marked changes in muscular tone, asphyxia. Despite the fact that its cause still remains unknown, many centres relate ALTE with gastroesophageal reflux disease (GERD) and therefore recommend medical treatment of GERD to those patients with ALTE. However there are very few articles that proof the efficacy of surgical treatment in patients with ALTE and GERD. We carried out a retrospcective review between 2000 and 2008 of those patients with ALTE who underwent a laparoscopic antirreflux procedure. The study included the realization of contrast x-ray, pHmetry and laryngeal, digestive and bronchial endoscopy. During this period antirreflux (with either Nissen or D'Or technique) procedure was carried out by laparoscopic approach in the patients with ALTE and GERD. Median of gestational age was 32 week, mean birth weight was 1800 g, mean age at the time pof surgery was 217 days (range 32-410). All these patients had previously presented 3 or more events of ALTE and had been treated medically for GERD. pHmetric studies were no conclusive, In 6 out of 15 patients had different grades of arithemoid oedema. All the patients presented gastroesophageal reflux (grades II-III) in the constrast x-ray. Mean follow up was 1258 days. 7 from 8 patients presented clear improvement. Morbimortality derived from surgery was null.

[Nonpalpable testes: short, middle and long-term results with the use of an exclusively laparoscopic technique]. / Testículo no palpable: resultados a corto, medio y largo plazo con la utilización de técnica exclusivamente laparoscópica.

Non palpable testis (NPT) has an incidence of 20% and clinical relevance derived from the possibility of malignant degeneration, fertility disfunction. Recently the development of minimally invasive surgery (MIS) allowed more accurate diagnosis and has become a new therapeutic tool. We carried out a retrospective study that included all the patients who underwent laparoscopic orchidopexy between 1998 and 2008. 156 patients were reviewed, which represent 179 testis units (TU). In 65 occasions the testis was placed in the internal inguinal orifice and in 68 occasions the testis was purely intraabdominal. Testicular atrophy was evidenced in 32 cases (7%). Laparoscopic orchidopexy was carried out in 152 TUs except in those that developed agenesia or atrophy-. A prothesis was placed after removing the remaining testis. 18 cases required a FowlerStephens. Inmediate postoperative complications were oedema (18 cases) and escrotal hematoma (9 cases). Testicular atrophy appeared in 12 cases after descent and in 3 cases after the first stage of the FowlerStephens. In 8 cases it was necessary to proceed to a second descent because of ascent after surgery. Laparoscopic orchidopexy has proved to be an efficient technique for the management of NPT which unifies the advantages of MIS and the outcomes of the conventional opened approach.

[Short term evaluation of transanal pull-through with automatic suture]. / Valoración a corto plazo del descenso transanal con sutura automática.

For the last ten years many centres have adopted transanal pull-through (TP) as the first choice technique for the treatment of Hirschsprung's Disease (HD) affected children. We present our experience, based on the endorectal pull-through with autosuture, which has not been reported up to now. According to our HD management programme, TP with autosuture should be performed in rectosigmoid forms of HD which are easily handled with outpatient care. Seven patients with HD whose ages ranged from 5-months-old to 5-years-old underwent EP with autosuture. We present the short term results of the evolution of our patients. Firstly, a laparoscopic procedure is carried out in order to obtain a biopsy from the transition zone. The second stage consists of the TP following the De La Torre technique, modified by the 21 mm circular autosuture. No new surgical operation was necessary. Passage of stools started between the second and fourth postoperative day. The most frequent complication was abdominal distention, found in an 85.7% of patients and resolved before being discharged. Hospital discharge took place between the fourth and the tenth postoperative day. Oral feeding was started in the 2nd-7th postoperative day. Medium term outcomes show a single case of complications: a patient Developer a skin stricture due to the low suture, which has been treated conservatively with rectal dilatations. Patients older than three (42.8%) are continent, although one presents occasional fecal soiling. The rest of the children present normal stools for their age. Automatic suture involves several advantages such as celerity and safety. We ought to point out that this method should not be used in children under 5 months because the autosuture size does not allow to do so.