Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children.

BACKGROUND: Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome. AIMS: To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery. METHODS: We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients' Visick score assessed parents' perspective. RESULTS: Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents' perspectives were excellent or good in 85 %. CONCLUSIONS: A significant positive impact of redo Nissen intervention on the patient's outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

Da Vinci Robotic Surgery in a Pediatric Hospital.

INTRODUCTION: Since the use of robotic surgery (RS) revolutionized some adult surgery procedures such as radical prostatectomy, it has been progressively and increasingly introduced in pediatric surgery. The aim of this study is to evaluate how the Da Vinci® Si HD technology impacts a pediatric public hospital and to define the use of a robotic system in pediatric surgery. MATERIALS AND METHODS: We prospectively included patients older than 6 months of age undergoing RS or conventional minimal access surgery (MAS): Study period ranges between February 2015 and April 2016. Surgical indications were defined after a detailed disease-specific diagnostic work-up. We analyzed surgical outcomes and the most relevant economic aspects. The 30-day postoperative complications were evaluated and retrospectively collected in an electronic database. RESULTS: From February 2015 to April 2016, we performed 77 procedures with RS and 84 with conventional MAS in patients with a median age of 77 and 98 months at surgery and a median weight of 20 and 23 kg, respectively. Median operative times were 130 and 109 minutes, respectively. We observed 9.1% of complications in the RS group and 6% in the MAS group and the difference was not statistically significant. Of note, 8 out of 77 RS procedures would have been performed with open classic surgery in case of conversion or failure of RS. CONCLUSIONS: This initial experience confirms that RS is as safe and effective as conventional MAS. A number of selected procedures performed with RS would only benefit from this approach, as it is not suitable for conventional MAS. Although economically demanding, in particular for a pediatric hospital, we firmly believe that centralization of care would allow pediatric surgeons adopting RS to perform complex reconstructive surgical procedures with great advantages for the patients and a minimal increase in overall costs for the health system.

Congenital Lung Malformations: Shifting from Open to Thoracoscopic Surgery.

BACKGROUND: Over the years the need for surgical treatment, timing of intervention, and the type of surgical approach have been discussed, but the treatment of congenital lung malformations remains controversial. The aim of this study was to compare the thoracotomy approach with the thoracoscopic technique by evaluating different surgical outcomes (duration of surgery, postoperative hospital stay, and complications). METHODS: All patients operated from January 2011 to March 2015 for suspected congenital cystic lung were included in the study. Patients treated for congenital lobar emphysema and tracheobronchial neoplasms were excluded from the study. RESULTS: In the analyzed period, 31 asymptomatic patients were treated: 18 lung resections were performed with thoracotomy (Group A) and 13 with the thoracoscopic approach (Group B). No significant differences were observed between the age and weight at surgery, length of the procedures, complications, and the need for postoperative intensive care between the two groups. The postoperative hospital stay in Group A was twice that for Group 2 (p = 0.0009). CONCLUSION: Comparing thoracoscopic surgery with the traditional open approach, we confirmed the superiority of minimally invasive treatment in terms of postoperative hospital stay. Common technical recommendations can help pediatric centers to develop the thoracoscopic approach for the treatment of congenital pulmonary malformations.

Cone-like resection, fistulectomy and mucosal rectal sleeve partial endorectal pull-through in paediatric Crohn's disease with perianal complex fistula.

BACKGROUND: Perianal abscesses and fistulae have been reported in approximately 15% of patients with paediatric Crohn's disease and they are associated with poor quality of life. Several surgical techniques were proposed for the treatment of perianal Crohn's disease, characterized by an elevated incidence of failure, incontinence, and relapse. Aim of our study was to present the technical details and results of our surgical technique in case of recurrent, persistent, complex perianal ano-rectal destroying Crohn's disease not responding to medical treatment. METHODS: Data of patients who underwent surgical treatment (cone-like resection, fistulectomy, sphincter reconstruction, endorectal advancement sleeve flaps like in Soave endorectal pull-through) for complicated high-level trans, inter or suprasphincteric fistulae between January 2009 and June 2014 were retrospectively reviewed. RESULTS: 20 surgical procedures were performed in 11 patients (males 72.7%) with transsphincteric (n=5), intersphincteric (n=4) and suprasphincteric (n=2) fistulae. Three patients needed a second treatment. Two patients needed more than 2 surgeries and one temporary colostomy. No patient presented anal incontinence at 15 months' median follow-up. CONCLUSIONS: Although several procedures may be required to obtain a complete remission of perianal lesions, in our series the proposed surgical technique seemed effective and safe, preserving anal continence in all treated cases and reducing the need of faecal diversion.