[Use of laparoscopy in neonatal pathology: our experience]. / Uso de la laparoscopia en la patología duodenal: nuestra experiencia.

The neonatal duodenal pathology has been diagnosed and treated with open surgery for many years. The use of minimally invasive techniques is widely use today on pediatric surgery, but its use on neonatal pathology poses a challenge. We have conducted a study of the 8 neonatal patients with duodenal obstruction that were operated with a laparoscopy in our hospital between 2001 and 2007. The analyzed parameters were the gender, prenatal diagnostic, type of duodenal malformation, weight at birth, hospitalization stay, start of feeding, complications and follow-up. In our sample (6 girls and 2 boys) the 62.5% of the cases was diagnosed after a prenatal ultrasound scan. The duodenal malformations discovered were 5 atresias, 2 webs and 1 anular pancreas. In all the cases, the feeding started by means of a trans-anastomotic probe 48 hours postoperatives. There were 3 complications: one re-surgery and 2 stenosis of anastomosis. The average hospitalization stay was of 27 days with a mean follow-up of 3 years. We think that laparoscopy is a good method for the treatment of the neonatal duodenal pathology, although the scarce volume of our sample does not allow us to generalize the technique.

[Thoracoscopic lobectomy in patients with congenital cystic adenomatoid malformation]. / Lobectomía toracoscópica en pacientes con malformación adenomatoidea quística.

BACKGROUND: The management of asymptomatic patients with congenital cystic adenomatoid malformation (CCAM) is controversial. This report evaluates the video-assisted thoracoscopic (VAT) lobectomy in children with this malformation, and the different intraoperative complications and their resolution are discussed. METHODS: Six patients with CCAM underwent video-assisted thoracoscopic lobectomy. All the patients were under one year and all of them were asymptomatic at the diagnosis. The procedures were performed with single lung ventilation and the chest was insufflated with a low flow and pressure to complete collapse of the lung. We used 3 or 4 thoracoscopic ports depending on the difficulty of the dissection. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. The following features have been taken into account: age at diagnosis, localization, surgical technique, complications, hospital stay, results, and time of follow-up. RESULTS: Four lesions were on the right lower lobe (66.7%) and two (33.3%) in the middle lobe. All the procedures were completed thoracoscopically. Chest tubes were left in all cases. Two patients (33.3%) showed postoperative hemothorax but it didn't need blood transfusion. Mean hospital stay was 6 days. At the moment all the patients are asymptomatic with and the mean time of follow-up has been 2 years and 8 months. CONCLUSIONS: VAT lobectomy avoids the long-term morbidity associated to an open thoracotomy and therefore it is a safe and efficacious technique in asymptomatic children with CCAM. Moreover, a greater number of cases are necessary to validate and to improve the technique.

[The role of tracheobronchial stenting in the management of pediatric airway obstruction]. / El papel de las prótesis traqueobronquiales endoluminales en la patología obstructiva de la vía aérea del niño.

PURPOSE: Tracheobronchial stenting can aid in the management of pediatric airway problems. We reviewed our experience to determine the role of endoscopic airway stents in children. METHODS: Sixteen children (Age range: 10 days- 19 years) underwent 28 tracheobronchial stents in the period 1991-2006. The stent type chosen depended on patient age and location. All procedures were done under general anesthesia with bronchoscopy. The following features have been taken into account: etiology, obstruction diagnosis, stent type, localization,,associated anomalies, complications, results, and time of follow-up. RESULTS: Etiology of the tracheobronchial obstruction included tracheobronchiomalacia in 13 patients (81.3%), tracheal stenosis in 2 (12.5%) and glotic stenosis in one case (6.2%). The stent used were 15 Palmaz (53.5%), 7 Dumon (25%), 4 Montgomey (14.5%), 1 Poliflex (3.5%) and one Dynamic stent (3.5%). More than one stent were undertaken in seven cases (43.7%). 16 patients had tracheal stents, 11 children had bronchial stent and one infant a carinal stent. Five complications are reported (two patients developed granulation tissue, two stents migrated, and a child presented a left lung atelectasis) and five patients died (only one case related to tracheobronchial stenting). Results have been satisfactory in 14 patients (87.5%) and the mean time of follow-up has been two years and ten months (range 2 months- 12 years and 6 months). CONCLUSIONS: The tracheobronchial stenting in children may represent a valid treatment option for many sick children in particular circumstances. The long-term outcome remains uncertain but the medium-term outlook is encouraging.

[Minimally invasive surgery for the management of congenital diaphragmatic patology]. / Manejo de la patología diafragmáitica congénita con cirugía mínimamente invasiva.

INTRODUCTION: Minimally invasive surgery (MIS) plays a major role in pediatric surgery. We reported our experience in MIS management of congenital diaphragmatic patology (CDP). PATIENTS AND METHODS: The authors collected date on children who underwent a MIS for CDP repair from 1998 until 2006. The following features have been taken into account: lesion type, approach, surgical technique, complications, hospital stay and time of follow-up. RESULTS: From 1998 until 2006 11 patients (age range: 2 days-6 years and 6 months) with CDP had undergone an attempt at MIS repair: 6 patients with posterolateral hernia (36.4%), 4 with Morgagni hernia ( 54.5%) and a congenital diaphragmatic eventration case (9%). Eight patients 8 (72.7%) were treated using laparoscopy and three cases using thoracoscopy. Three patients were treated as newborns (27.2%). Four patients presented complications (36.3%): two patients who were repaired initially laparoscopically were converted to a transabdominally approach and two patients had recurrent herniation, which were repaired with MIS. Actually all cases were asymptomatic with a mean time of follow-up of 1 year and 8 months (range: 3 months-two years). CONCLUSIONS: MIS is a feasible, safe, easy to perform and efficient approach to repair CDP but it needs selection criteria for successful outcome.

[Laparoscopic inguinal herniorrhaphy in children. First results]. / Resultados iniciales del tratamiento de la hernia inguinal por vía laparoscópica.

INTRODUCTION: The inguinal hernia repair in the child has a new alternative, the laparoscopic repair. We study our initial results obtained with this technique. We evaluate the indications and the efficiency. MATERIAL AND METHODS: 150 patients have been operated with an initial diagnosis of hernia inguinal or crural. Usually this technique is realized with three ports: we put the umbilical one (5mm) for the scope and two ports (3 mm) placed in flanks. The repair was realized in purse string fashion or interrupted or noninterrupted suture with non-absorbable suture (polipropylen) 3-4/0. RESULTS: Indications of the herniorraphy were: (12%) recurrent hernia, bilateral hernia (28%), association inguinal hernia inguinal and umbilical (39%), crural hernia (4%) and in 16% incidental hernia. Most of them (137) was treated in purse string fashion, (11) non interrupted suture and 12 interrupted suture. No conversion to open was require in any case. Haematoma for puncture of the spermatic vessels was seen in 6 cases (1,4%). Today we do this surgery in ambulatory way. We have had 2 recurrent hernias (1%) that were treated again laparoscopicaly. CONCLUSIONS: We can't extract conclusion from this study because of the number of patients but we think that the laparoscopic treatment of inguinal hernias can offer advantages in selected cases.

[Pleural empyema. Thoracoscoopic treatment]. / Empiema pleural. Tratamiento toracoscópico.

OBJECTIVE: To compare the use of primary and secondary thoracoscopy in children with parapneumonic empyema. MATERIAL AND METHODS: We present a retrospective study of 24 children entered our hospital between years 1998 and 2003. RESULTS: Early thoracoscopy doesn't influence in length of stay. 12 children (50%) were treated with previous chest tube and other 12 children (50%) without it. There is statistical significance in length of hospital stay. The days with postoperative fever didn't decrease, but it was seen if we compare it from the beginning of the disease. CONCLUSIONS: An early thoracoscopy decrease length of hospital stay and the duration of fever postoperative.

[Results of laparoscopic treatment of complicated appendicitis]. / Resultados del tratamiento laparoscópico en la apendicitis complicada.

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated cases is controversial. We show our experience with 40 cases of complicated acute appendicitis treated by means laparoscopy between February 2000 and October 2002. In every case we used 3 ports, one umbilical and the other two in both lower quadrants. The appendix was gangrenous in 31 patients and in the other 9 was perforated. Appendectomy was performed in an extracorporeal way in most of the cases. Average surgical time was 71 minutes and mean hospital stay was 8.8 days. Intraoperative complications occurred in 8 cases (20%) and postoperative complications were observed in 9 patients (22.5%). Four patients were reoperated (2 open and 2 laparoscopic) in order to drain two abscesses and treat two obstructions. The results of this serie is compared with another group of 40 complicated appendicitis operated in a classic open way in the same period of time. Postoperative complications were less often in the laparoscopic group. Oral intake, need for analgesia and hospital stay are more favorable in the laparoscopic group.

[Alternative treatment of gastroesophageal reflux: endoluminal gastric plication]. / Tratamiento alternativo del reflujo gastroesofágico: plicatura gástrica endoluminal.

Gastroesophageal reflux is a common chronic disorder that is presented in infants under different clinical pictures. Adolescents with heartburn, dependent on acid supression therapy is a group of patients refered with increased frequency to pediatric surgeons. To date, the accepted methods of management are long term medication or surgery. Recently, different endoscopic techniques have been described to treat gastroesophageal reflux. Endoscopic antireflux suturing is one of this developed methods. In this paper, we present the preliminary results in the treatment of pediatric patients with an endoscopic suturing device. The procedure was accomplished in six patients and the results were analized 6 months after the placement of the sutures. We have obtained an improvement in clinical symptoms reduction, in terms of frequency as well as in intensity. Acid supression therapy was also reduced significantly. There were no complications during the endoscopic procedure, neither in the postoperative course. Patients, were agree with the technique and the clinical results obtained. Endoscopic suturing is a safe procedure that can be an alternative in the treatment of selected patients with gastroesophageal reflux, in the pediatric age group.

[Thoracoscopic repair of esophageal atresia]. / Tratamiento toracoscópico de la atresia de esófago.

We present the first three cases of esophageal atresia with tracheoesophageal fistula treated with a thoracoscopic approach in our Service. The technique was accomplished through three trocar inserted in the right hemithorax. Carbon dioxide insufflation was required for lung retraction Primary correction was carried out in all the cases without major perioperative complications. The mean surgical time was 240 minutes. One patient had an anastomotic leak, resulting in a complicated postoperative course. The leak healed on conservative treatment. The others two patients were fed at the seventh postoperative day. Mean hospital stay in these cases was 12 days. Although thoracoscopic repair of esophageal atresia with fistula is a currently feasible technique that offers different advantages on the conventional open technique, a greater number of cases is needed in order to advance in the learning curve and determine the exact place that this technique can have in the future treatment of esophageal atresia.

[Jejunal diaphragm. Laparoscopic treatment in newborns]. / Atresia yeyunal membranosa. Tratamiento laparoscopico en periodo neonatal.

Intestinal obstructions in newborns secondary to atresias or membranes have been treated until the current moment through laparotomy and resection with anastomosis. Recently, it has been reported the use of minimally invasive techniques to correct this congenital anomaly. We present a case of jejunal diaphragm treated in our Service. Diagnosis and treatment by mean of endoscopic techniques was achieved in the fourth day of life. Operative time was 180 minutes. Postoperative course was uneventful. Results in terms of function and cosmetic were excellent. Laparoscopic management in selected cases of intestinal atresia has proven to be safe and effective and represents an alternative to neonatal open surgery.

[Congenital colonic stenosis]. / Estenosis congénita de colon.

The colon is the least common site of congenital intestinal stenosis and atresia and accounts for 5-15 % of all of these abnormalities. We present the case of a 2-month-old boy who presented vomiting, constipation, weakness, and abdominal distension. Contrast enema and colonoscopy revealed an abrupt change in caliber in the sigmoid colon and, after ruling out other disorders, a diagnosis of colonic stenosis was made. Laparoscopy under total anesthesia was performed and a stenotic area in the sigmoid colon and proximal dilatation were identified. A small incision was made and the stenotic segment was removed. Video-assisted resection and end-to-end anastomosis were performed and the child made and uneventful postoperative recovery. Contrast enema after surgery showed good anastomosis and normal bowel diameter. At the age of 18 months the patient is asymptomatic and his stools are normal. With laparoscopy, visualization of the abdominal cavity was magnified and detailed, the affected intestinal segment was easily identified and other diseases were ruled out. Recovery was rapid and the functional and esthetic results were excellent.

[Analysis of anti-reflux surgery failure]. / Análisis del fracaso de la cirugía antirreflujo.

Recurrent gastroesophageal reflux following fundoplication is a challenging problem, because it is usually refractory to medical treatment and a second, technically difficult, antireflux operation is required. Different factors that may contribute to surgery failure have been identified in children. We present 8 cases who underwent redofundoplication after failed procedures, from a total number of 96 patients operated on due to gastroesophageal reflux. Four patient's had their initial fundoplication performed at our institution. Six patients were neurologically impaired, six had chronic pulmonary disease, and two had esophageal atresia. The main presenting symptoms were recurrent vomiting (n = 8) and aspiration (n = 4). Gastroesophageal reflux was confirmed by barium swallow and endoscopy. Operative findings showed wrap breakdown in two cases, warp breakdown associated with hiatal hernia in five, wrap breakdown associated with paraesophageal hernia in two cases, and paraesophageal hernia with normal wrap in one. A second Nissen procedure were performed in five cases, whereas a Collis-Nissen gastroplasty was realized in three with a short esophagus. Six patients had a successful outcome remaining symptom free, one has severe disphagia, and one has recurrent vomiting. In our experience, patients with recurrent gastroesophageal reflux disease should undergo an antireflux procedure tailored to specific anatomic or functional abnormalities.