Neonatal Paratesticular Abscess as the Greatest Mimicker of Testicular Torsion.

INTRODUCTION: The management of acute scrotal swelling can be challenging in neonatal age, with scrotal abscess being great mimickers of testicular torsion. CASE PRESENTATION: We report a 12-day-old previously healthy male infant who presented with 72 h of increasing right-sided scrotal swelling, without fever or irritable behavior. The left testicle was palpable, but the right side was too swollen to palpate a testicle, with absent cremasteric reflex. Biochemical analysis was normal and Doppler sonography demonstrated a hypoechogenic avascular lesion compressing the right testis, without intratesticular flow. Due to these findings, surgical exploration was undertaken on suspicion of potential testicular torsion. Purulent material was encountered and cultured. The testis and epididymis were covered by thick necrotic fibrinous exudate, with no spermatic cord torsion. Gentamicin and vancomycin were begun immediately. The patient remained afebrile and the scrotal induration gradually subsided. Urine and blood cultures were sterile. On the second postoperative day, cultures yielded Escherichia coli sensitive to gentamicin. One-month follow-up testicular ultrasound demonstrated complete inflammation resolution. CONCLUSION: Paratesticular abscess may be considered as the greatest mimicker of testicular neonatal torsion, due to the frequent absence of classical signs of inflammation. Early surgical exploration can be diagnostic and therapeutic and should be performed in these cases.

Clinical-pathological correlation of endoscopic findings in eosinophilic esophagitis in the pediatric population.

Eosinophilic esophagitis (EoE) is an immunologic disorder of the esophagus with an increasing incidence in our region of 8.1 cases per 100,000 inhabitants per year. It is characterized by dysphagia, and its diagnosis requires esophagoscopy with biopsies for histopathological analysis, which macroscopically reveals certain characteristic endoscopic findings, though their diagnostic utility remains uncertain. The correlation between these endoscopic findings and the histopathological diagnosis of EoE continues to be a subject of controversy in the pediatric population. This study evaluates the clinical-pathological association of different endoscopic abnormalities in EoE. We conducted an analytical study of patients under 15 years old who underwent esophagoscopy due to highly suspicious symptoms of EoE at a pediatric hospital between 2015 and 2022.

Correlation of endoscopic findings with histological alterations in pediatric ulcerative colitis.

Ulcerative colitis (UC) is a chronic and relapsing inflammatory bowel disease (IBD) characterized by abdominal pain and bloody diarrhea. Its diagnosis requires endoscopy and biopsies for histopathological analysis, revealing characteristic endoscopic findings. Currently, the correlation between these endoscopic abnormalities and the histopathological diagnosis of UC remains a controversial topic in pediatrics. This study evaluates the clinicopathological association of various endoscopic alterations in UC. We conducted an analytical study of patients under 15 years old who underwent upper and lower gastrointestinal endoscopy for suspected IBD at a pediatric hospital between 2015 and 2022.

Mortality predictive factors in congenital hepatic hemangioma: a case-control study.

Congenital hepatic hemangiomas (CHHs) are benign vascular tumors whose clinical, histological, and genetic correlation has recently been described in patients with long-term survival, although no mortality risk factors have been identified to date. The aim of this study is to analyze predictors of mortality in patients with CHH. A retrospective single-center case-control study of consecutive CHH patients diagnosed in our institution between 1991 and 2021 was performed, who were classified into two groups according to their survival. Demographic, gestational, imaging, and laboratory data at diagnosis were collected and compared between both groups. A total of 29 patients were included (12 males; 17 females) of whom 5 died as a result of CHH evolution due to cardiac failure and coagulopathy, with a median age of 11 days until death. No differences in demographic or gestational data were reported. There were neither differences when comparing imaging tests, nor in location, number of affected liver segments, or CHH estimated volume. Upon laboratory data at diagnosis, deceased patients had a significant elevation of median liver enzymes [glutamic-oxaloacetic transaminase (359 u/L vs. 45 u/L; p < 0.01) and glutamic-pyruvic transaminase (313 u/L vs. 20 u/L; p < 0. 01)], as well as a decreased median platelet count (85,250/µL vs. 337,000/µL; p < 0.01), prothrombin activity (54% vs. 93%; p < 0.01), and fibrinogen (131 mg/dL vs. 284 mg/dL; p < 0.01), with no differences in blood count or biochemistry data. CONCLUSIONS: CHH clinical behavior can be innocuous or life-threatening. Thrombocytopenia, coagulation disorders, and increased liver enzymes at diagnosis seem to be the main predictors of mortality. WHAT IS KNOWN: • Congenital Hepatic Hemangiomas (CHHs) are benign vascular tumors whose clinical behavior can be innocuous or life-threatening. WHAT IS NEW: • Thrombocytopenia, coagulation disorders and increased liver enzymes at diagnosis seem to be the main predictors of mortality in these patients.

The effectiveness of matrix ablation with silver nitrate in the treatment of ingrown toenails. A single-center case-control study.

BACKGROUND: Partial onychectomy with chemical matrixectomy is considered the gold standard treatment for stage II-III ingrown toenails (IT). However, there are scarce reports describing the use of silver nitrate in IT management in adolescents. Our aim is to analyze the effectiveness of matrix ablation with silver nitrate and compare it with partial onychectomy by electrocautery. METHODS: A retrospective study of adolescent patients with stage II-III IT was performed. Those who underwent electrocautery matricectomy in a major outpatient surgical center (Group A) and those who were treated with silver nitrate at an outpatient clinic (Group B) were compared. Efficacy was determined by recurrence and postoperative infection rates. RESULTS: Two hundred and nine patients were included (86 group A; 123 group B), with a total of 382 partial onychectomies (151 group A; 231 group B). Group B patients exhibited a lower recurrence rate (4.7%) when compared to group A (11.2%, p = .02), and had a lower postoperative infection rate (4.0% group A vs. 1.7% group B; p = .18), although not statistically significant. CONCLUSION: Silver nitrate chemical matricectomy after partial onychectomy is an effective treatment for IT in adolescents, with few postoperative complications and low recurrence rate. Therefore, it should be considered as a possible alternative to electrocautery matricectomy.

How does the number of training years in pediatric surgery affect appendectomy outcomes?

INTRODUCTION: Appendectomy has traditionally been considered as a training operation for junior pediatric surgeons during their training period. However, with the increase of laparoscopic appendectomy, there has been a growing concern about the performance of this procedure by junior trainees. Our aim is to analyze intra-/postoperative appendectomy outcomes according to the number of training years during Pediatric Surgical residency training program. METHODS: A retrospective study was performed in patients who underwent appendectomy between 2018 and 2021 in our institution, who were divided into 5 groups according to the number of training years of the junior surgeon who performed the intervention (Y1-Y5). Demographics, complicated appendicitis rate, operation time, and postoperative complications were compared. A stratified analysis according to the technique performed (open/laparoscopic) was performed. RESULTS: A total of 1274 appendectomized patients were analyzed, of which 1257 (98.7%) were operated on by junior trainees (81 in Y1; 407 in Y2; 337 in Y3; 261 in Y4; and 171 in Y5) without demographic differences between groups. As the year of training increased, an elevation in complicated appendicitis rate was observed, although without statistically significant differences. However, laparoscopic/open appendectomies ratio increased with increasing year of training (p < 0.001). Operative time decreased significantly with increasing year of training (p < 0.001), both in open and laparoscopic appendectomies. There were no significant differences in postoperative complications, nor in the stratified analysis according to surgical technique. CONCLUSION: Appendectomy performed by junior pediatric surgery trainees can be considered a safe procedure from the first year of training, regardless of the technique used.

Does the timing of appendectomy affect outcomes and postoperative complications?

PURPOSE: There is controversy about the necessity of nighttime appendectomy. The aim of this study was to determine whether timing of appendectomy performance plays a role on postoperative complications. METHODS: A retrospective single-center comparative study was performed in children who underwent surgery for acute appendicitis between 2017 and 2021. Patients were divided into groups based on the time slot in which surgery was performed: morning (8:00 h-15:00 h), afternoon (15:00 h-22:00 h) and night (22:00 h-08:00 h). Demographics, intraoperative data, length of hospital stay, and postoperative complications were analyzed and compared. RESULTS: A total of 1643 patients were included: 337 were operated in the morning, 751 in the afternoon and 555 at night. We found no demographic differences. When comparing the intraoperative data, no differences were observed in the percentage of complicated appendicitis. Night group patients presented a higher percentage of open appendectomies (64.5%) when compared to afternoon (49.6%) and morning (46.2%) groups (p < 0.001). Surgery time was also significantly shorter in the night group (45.2 min ± 18.9 min) (p < 0.001). There were no differences in length of hospital stay, postoperative complications rate or readmission rate. CONCLUSION: These results show that in our institution time slot in which the appendectomy is performed has no consequences in postoperative outcomes and complications.

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes.

OBJECTIVE: Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter. METHODS: A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected. RESULTS: An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra. CONCLUSION: The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes.

PURPOSE: To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12 months. METHODS: A prospective observational study was conducted on HSCR patients under 12 months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected. RESULTS: A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4 months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3 kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72 min. The median hospital stay was 3 days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79 months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case. CONCLUSION: RSPT procedure for Hirschsprung's disease in children younger than 12 months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

Venous malformations: what do phleboliths tell us in the pediatric population?

PURPOSE: Phleboliths are often observed within Venous malformations (VM) and frequently indicated as cause of morbidity. The aim of this study is to investigate independent risk factors for phleboliths in a pediatric population and to determine if its presence influences clinical management. METHODS: We retrospectively review data from patients diagnosed with VM in a vascular anomalies center during a 5-year period. Associations between phleboliths and potential risk factors were assessed. A multivariable analysis, was performed to assess the influence of phleboliths in the need for surgery. RESULTS: We included 88 patients with a mean age of 10 years. Phleboliths were found in 33.0%. In univariate analysis, there were no significant differences between the two groups regarding age or gender, location, dimension or depth of the VM, pain and laboratory parameters. Multivariable analysis could not detect any independent risk factor for phleboliths. In contrast, multivariable logistic analysis revealed that when phleboliths were present, the need for surgical extirpation was more likely (p = 0.031). CONCLUSIONS: This study showed that patients who have phleboliths within their VM seem to require surgery more frequently. This constitutes an entirely innovative thought that could raise awareness to a lower threshold for surgery in this group of patients.

Robotic-assisted versus laparoscopic splenectomy in children: a costeffectiveness study.

Laparoscopic elective splenectomy is considered as a safe surgical treatment of spleen non-traumatic blood disorders. However, robotic assisted splenectomy is becoming a promising alternative, although there are scarce studies in pediatric patients. Our aim is to compare the effectiveness and associated costs of both procedures in children. A single-institution retrospective study was performed among consecutive children undergoing splenectomy between 2004 and 2021, who were divided according to the surgical approach: LAS group (laparoscopic splenectomy) and RAS group (robotic assisted splenectomy). Demographics, clinical features, intraoperative blood loss, surgery time, length of hospital stay (LOS), postoperative complications, need for postoperative blood transfusion, readmission rate and economic data were compared. A total of 84 patients were included (23 LAS group; 61 RAS group), without demographic or clinical differences between them. RAS patients presented lower intraoperative blood loss (42 ± 15 vs. 158 ± 39 ml; p < 0.021) and shorter surgery time (135 ± 39 vs. 182 ± 68 min; p = 0.043), with no differences in median LOS (3 days in both groups). No intraoperative complications or conversion was reported. Five postoperative complications were observed: 4 in LAS patients (17.4%) versus only one in RAS (1.6%; p = 0.021). One reintervention was required in LAS group due to hemoperitoneum 12 h after splenectomy. RAS patients had lower postoperative blood transfusion requirements (1.6% vs. 13.0%; p = 0.025) and lower readmission rate (3.3 vs. 17.4%; p = 0.042). No differences were observed when comparing the median economic costs ($25,645 LAS vs. $28,135 RAS; p = 0.215). Robotic assisted splenectomy may be considered as a safe and feasible option in children compared to the traditional laparoscopic approach. Level of evidence: III.

The Role of Indocyanine Green in Pediatric Gastrointestinal Surgery: Systematic Review.

The use of near-infrared fluorescence imaging with indocyanine green (ICG) is actually considered as a very useful tool in decision-making strategy during challenging surgical procedures with a growing evidence in the literature. Our aim is to perform a systematic review focusing on ICG applications in gastrointestinal surgery. We conducted a systematic review with narrative synthesis in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Medline, and EMBASE databases to identify articles describing the gastrointestinal perioperative use of ICG in children. We extracted data on study design, demographics, surgical indications, ICG dose, and perioperative outcomes. Eleven articles, including 94 pediatric patients, from 2013 to 2022 met the inclusion criteria for narrative synthesis in our systematic review, of which 6/11 (54.5%) were case reports, 4/11 (36.4%) were retrospective studies, and 1/11 (0.1%) were case series. Current clinical applications of ICG in gastrointestinal pediatric surgery included: esophagogastric surgery in 4/11 articles (36.4%), intestinal and pancreatic surgery in 3/11 articles (27.2%), and colorectal surgery in 4/11 articles (36.4%). ICG fluorescence in gastrointestinal pediatric surgery is a promising and safe technology that facilitates intraoperative localization of anatomical structures to achieve a more precise dissection and avoid injury to other adjacent tissues. It can be considered as a meaningful tool for assessing intestinal viability, as it provides objective data on tissue perfusion, and can impact the intraoperative decision in reconstructive surgeries requiring anastomosis. Future studies are needed to confirm these initial promising results. The lack of comparative and prospective studies is still the main limitation.

Ureteroinguinal Herniation with Consecutive Ureteral Stricture in a 2-Month-Old Infant: Case Report.

Inguinal herniation of ureter is an uncommon finding among children, with scarce reported cases in the literature to date, that can potentially lead to obstructive uropathy. We report a case of ureteroinguinal herniation discovered during an inguinal hernia repair in a patient with antenatally ultrasound finding of hydronephrosis. A 2-month-old infant with antenatal left hydronephrosis presented with left inguinal mass. Preoperative ultrasound showed an anechoic tubular image producing a mass effect on the left testicle, with suspected bladder herniation and/or dilated ureter toward the inguinal canal. An open surgical inguinal exploration was performed, where the left inguinal canal revealed a peritoneal sac and sliding of the dilated left ureter behind the sac, with a significant change in diameter, corresponding to the paraperitoneal variant of ureteroinguinal herniation. Ligation of the sac and replacement of the ureter into the retroperitoneum were performed, with improvement in the hydronephrosis observed on the ultrasound 1 month after the intervention. However, 6 months later, hydronephrosis worsening as well as the obstructive pattern observed in the diuretic renogram required removal of the stenotic ureteral segment and reimplantation of the healthy proximal segment in the bladder by open approach (Cohen's reimplantation). Follow-up ultrasound of the renal tract showed no dilatation of the upper renal tract and the renal function tests were normal. Currently, the patient is 2 years old and he remains asymptomatic. In conclusion, s igns of ureteral obstruction such as hydronephrosis in patients with inguinal herniation may suggest the possibility of an ureteroinguinal hernia. Preoperative diagnostic suspicion is essential.

The Role of Neutrophyl-to-Lymphocyte Ratio as a Predictor of Ovarian Torsion in Children: Results of a Multicentric Study.

INTRODUCTION: Pediatric ovarian torsion (OT) is an emergency condition that remains challenging to diagnose because of its overall unspecific clinical presentation. The aim of this study was to determine the diagnostic value of clinical, ultrasound, and inflammatory laboratory markers in pediatric OT. METHODS: We performed a retrospective multicentric case-control study in patients with clinical and ultrasound suspicion of OT, in whom surgical examination was performed between 2016-2022 in seven pediatric hospitals. Patients were divided into two groups according to intraoperative findings: OT group (ovarian torsion), defined as torsion of the ovarian axis at least 360°, and non-OT group (no torsion). Demographics, clinical, ultrasound, and laboratory features at admission were analyzed. The diagnostic yield analysis was performed using logistic regression models, and the results were represented by ROC curves. RESULTS: We included a total of 110 patients (75 in OT group; 35 in non-OT group), with no demographic or clinical differences between them. OT-group patients had shorter time from symptom onset (8 vs. 12 h; p = 0.023), higher ultrasound median ovarian volume (63 vs. 51 mL; p = 0.013), and a significant increase in inflammatory markers (leukocytes, neutrophils, neutrophil-to-lymphocyte ratio, C-reactive protein) when compared to the non-OT group. In the ROC curve analysis, the neutrophil-to-lymphocyte ratio (NLR) presented the highest AUC (0.918), with maximum sensitivity (92.4%) and specificity (90.1%) at the cut-off point NLR = 2.57. CONCLUSIONS: NLR can be considered as a useful predictor of pediatric OT in cases with clinical and ultrasound suspicion. Values above 2.57 may help to anticipate urgent surgical treatment in these patients.

Simultaneous Robotic-Assisted Splenectomy and Cholecystectomy in Children: Is It Safe and Effective?

Background: Hematologic conditions such as hereditary spherocytosis, sickle cell disease, and idiopathic thrombocytopenic purpura are frequently linked to cholelithiasis. In instances where symptoms are present, simultaneous cholecystectomy and splenectomy are commonly recommended. Our aim was to assess the outcomes of robotic-assisted procedures conducted for simultaneous surgical issues involving the spleen and gallbladder in pediatric patients. Materials and Methods: We have made a simultaneous retrospective study of children with hereditary hematological diseases who underwent combined robotic-assisted splenectomy and cholecystectomy at our institution from January 2010 to December 2021. Demographics, clinical features, intraoperative data, length of hospital stay, postoperative complications, and follow-up outcomes were analyzed. Results: A total of 11 patients (6 male; 5 female) were included, with a mean age of 13.9 ± 4.4 years (range 8-17). Hereditary spherocytosis was the most common disease (7 cases), followed by sick cell disease (4 cases), with associated symptomatic gallbladder litiasis in all of them. Both operations were carried out using the da Vinci® Surgical Si System in a single docking robotic platform (four robotic arms). Median total surgery time was 145 minutes (Q1-Q3: 115-162). Minimal intraoperative bleeding was recorded (mean 45 ± 15 mL), with no intraoperative complications or conversion. Median length of hospital stay was 3 days (Q1-Q3: 2-4). There were no cases of surgical wound infections or postoperative bleeding documented. Conclusion: Simultaneous robotic-assisted splenectomy and cholecystectomy can be considered safe and feasible interventions in children with hematological diseases that affect both the spleen and the gallbladder. However, further research is needed to enhance the existing evidence and establish a standardized approach.

Preliminary results of the use of carboxytherapy in the treatment of pathologic scars: A minimally invasive alternative.

BACKGROUND: Carboxytherapy involves injecting carbon dioxide in the dermal and subcutaneous layers to achieve an increase in the local microvascularization of the tissue where it is applied. Our aim is to analyze its effectiveness in the treatment of pathological scars, as well as its adverse effects. METHODS: We conducted a prospective single-center study in patients under 18 years of age with atrophic and hypertrophic scars caused by surgical interventions or trauma, mainly burns. Each patient underwent two sessions, 6 weeks apart in time. Scar quality was evaluated using the Vancouver Scar Scale before the first session and 6 weeks after the second session. Adverse effects observed during the procedure and at follow-up in outpatient clinic were collected. RESULTS: A total of 16 patients were included (5 males; 11 females), with a median age of 12.7 years (interquartile range 8.5-15.2), in whom 25 pathologic scars were treated (14 atrophic and 11 hypertrophic). All sessions were performed under sedation, and patients were discharged the same day, without the need for hospitalization. Regarding scar quality, an improvement was observed in the median Vancouver scale score at 6 weeks after the second session (7 points) compared to the initial median score (12 points), this difference being statistically significant (p = 0.031). No serious adverse effects were observed during the procedure or during subsequent follow-up, with a median follow-up of 14 weeks. CONCLUSIONS: Carboxytherapy is an effective and safe minimally invasive therapy for pathologic scars, achieving a significant improvement in scar quality, with almost no contraindications. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Prospective Single-Center Case Series.

Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study.

INTRODUCTION: Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children. METHODS: A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared. RESULTS: A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012). CONCLUSION: Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.

Robotic-assisted vs. Laparoscopic Heller's Myotomy for Achalasia in Children.

INTRODUCTION: Robotic-assisted Heller-Dor procedure has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia in children. Our aim is to compare the effectiveness, safety and associated costs between both procedures. METHODS: A retrospective single center study was conducted among consecutive children operated for achalasia (Heller-Dor operation) between 2005 and 2021, who were divided into two groups according to the surgical approach: laparoscopic (LAP-group) or robotic (ROB-group). Demographics, clinical features, surgery time, length of hospital stay (LOS), postoperative complications, long-term outcomes and economic data were compared between both groups. RESULTS: A total of 24 patients were included (12 in LAP-group; 12 in ROB-group), with no demographic or clinical differences between them. ROB-group patients presented lower intraoperative blood loss (23 ± 15 vs. 95 ± 15 ml; p < 0.001), shorter surgery time (178 ± 25 vs. 239 ± 55 min; p = 0.009) and shorter LOS, with a median of 2 days (Q1-Q3: 2-3) when compared to LAP-group (4 days [Q1-Q3:3-5]; p = 0.008). Three post-operative complications were reported, all in LAP-group (2 esophageal perforations and 1 esophageal tightness). After a median follow-up of 11 years, ROB-group patients presented fewer recurrences (0 vs 5; p = 0.039), less reintervention rate (0 % vs 41.7 %; p < 0.039) and lower associated economic costs (28,660$ vs. 60,360$; p < 0.001). CONCLUSION: This is the first comparative study of robotic and laparoscopic treatment of achalasia in children. Initial outcomes of robotic-assisted Heller-Dor procedure suggests some intraoperative (less blood loss and surgical time) and postoperative advantages (fewer complications and reinterventions). However, long-term studies with larger numbers of patients are needed. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Indocyanine green navigation in minimally invasive resection of multiple metachronous pulmonary metastases of hepatoblastoma.

Pulmonary metastases from hepatoblastoma (HB) have traditionally been identified by preoperative computed tomography scan image evaluation, and intraoperative visual and palpatory examinations through thoracotomy have been generally recommended. However, the safety and accuracy of surgery can be problematic in patients with small multiple lung metastases due to postoperative respiratory dysfunction risk secondary to decreased residual lung capacity in wedge resections. We present an 8-month-old patient with metastatic HB with multiple metachronous pulmonary lesions in whom thoracoscopic lung resections were performed guided by indocyanine green (ICG) administered intravenously 24 h earlier (0.5 mg/kg). ICG fluorescence allowed identification and limited resection of lung parenchyma, avoiding postoperative respiratory dysfunction. A total of 16 lung lesions were resected during four operations (two bilateral and two right thoracoscopies), with no postoperative complications. ICG-guided thoracoscopic surgery allowed identification and resection of metastatic nodules in both lungs during the same procedure, achieving a hospital stay of less than 3 days for each intervention. The patient is currently 24 months old and remains asymptomatic, with no distant disease at the last imaging control. ICG-guided resection via a thoracoscopic approach is particularly useful in patients with multiple and/or metachronous metastases requiring multiple surgical interventions.