Grade IV fibrosis interferes in biliary drainage after Kasai procedure.

OBJECTIVES: Biliary atresia (BA) is the most common cause of liver transplantation in children. The earlier the treatment is done, the better the prognosis. The aim is to evaluate the impact of late diagnosis in children with BA, including the histopathological findings and success rate of biliary drainage in patients submitted to hepatic portoenterostomy (HPE). MATERIALS AND METHODS: A retrospective study of cases of BA in the Department of Pediatric Surgery, Federal University of São Paulo (UNIFESP) between 1998-2011. We found 63 cases of BA; of these, 42 underwent HPE and 21 were referred for liver transplantation. Clinic and pathologic data were evaluated. RESULTS: The HPE was performed with a mean age of 86.5 days, with 16.6% having the operation at 60 days or earlier; 59.2% between 61 and 90 days; and 23.8% after 90 days. Successful biliary drainage occurred in 31% of surgeries, Mean days when HPE drained was 69.1 days, and 94.3 days when the surgery did not drain (P = .05). All patients who were successfully drained, did not have grade IV fibrosis on histology. In cases in which surgery was performed after 60 days that had not drained, 25% had grade IV fibrosis on biopsy (P = .0469). CONCLUSION: The age of HPE relates to better prognosis of the disease. It was found that the rate of grade IV fibrosis is higher in no drainage patients. All patients with grade IV fibrosis had no biliary drainage.

Eosinophilic infiltration of the esophagus: gastroesophageal reflux versus eosinophilic esophagitis in children--discussion on daily practice.

BACKGROUND/PURPOSE: Children presenting with persistent symptoms attributed to gastroesophaeal reflux disease (GERD) that are unresponsive to both medical and surgical therapies are commonly submitted to esophageal biopsies, the results of which show an abnormal presence of eosinophils. In this setting, eosinophilic esophagitis may be the correct diagnosis. The purpose of this report is to clarify the importance of esophageal eosinophilic infiltration, regardless of whether associated with acid reflux, ie, as an independent symptomatic entity, when treating a patient with refractory GERD. METHODS: Two boys, aged 8 and 7 years, had the classic symptoms of GERD. They were treated with antacid without improvement of the esophagic lesions. Subsequent esophageal biopsy results showed marked eosinophilic infiltration. From this moment on, eosinophilic esophagitis started to be considered the main diagnosis. RESULTS: Although eosinophilic infiltration caused by GERD is very frequently found in esophageal biopsy, in case of refractory drug treatment and microscopic findings of a great number of eosinophils and mast cells, eosinophilic esophagitis must be considered. This disease is better treated with corticoids instead of antacid drugs. It explains the reason some patients do not respond to antacid and surgical treatment and remain symptomatic with esophagic lesions. CONCLUSIONS: In refractory cases of GERD, eosinophilic esophagitis must be considered before any surgical measure.

Cecal duplication causing a disappearing abdominal mass in an infant.

Duplications of the alimentary tract are rare malformations. A case of a 2-year-old girl with an intestinal intussusception caused by a cystic duplication of the cecum is presented. This case report is justified by its clinical features and the difficult diagnosis, which was only confirmed during surgery. Ultrasonography had documented an abdominal mass that then disappeared and later reappeared, leading to surgical indication. During surgery, the intussusception within the abdomen was reduced, and right hemicolectomy was performed around the mass in the interior part of the cecum and appendix, with ileocolic anastomosis. On resecting the cecum, a cystic duplication measuring 4 x 3 cm was observed, with a granular mucous layer, an ulcerated hole in its interior, and inflammatory reaction. The patient had an uneventful recovery and was discharged on the fourth postoperative day.

Thoracoscopic esophagectomy in children.

Minimal access surgery is an alternative to open surgery in esophageal resections. Thoracoscopic surgery has been utilized for both benign and malignant esophageal lesions and is a complex and challenging surgical procedure that can provide some benefits in comparison with open thoracotomy. Many studies have described laparoscopic or thoracoscopic-assisted esophagectomy in adults. So far, to the best of our knowledge, there is no study about thoracoscopic esophagectomy in children. This report describes 2 pediatric cases of benign esophageal lesions: one stricture after accidental ingestion of caustic soda and one esophageal stenosis after thyroglossal duct complication. Both patients were submitted to thoracoscopic esophagectomy combined with laparotomy and open cervical exploration with success. This procedure presents some potential advantages when compared with open esophagectomy: shorter hospital stay, precise dissection of mediastinal structures, less postoperative pain, less blood loss during surgery and less long-term discomfort. In our cases, thoracoscopic surgery for children showed the same benefits as in adults. Although very feasible, it should not be attempted without sufficient training and should be carried out only in specialized medical centers and by surgeons with adequate experience with open esophagectomy.

Epigastric heteropagus twinning.

Conjoined twins is a very rare condition that represents, sometimes, a real challenge for pediatric surgeons. There is an even rarer situation, called heteropagus twinning, when one of the twins is not completely formed (parasite) and dependent of the well-formed one (autosite). The authors present a case of heteropagus twins in which the parasite was attached to the epigastrium of the autosite. In this situation, the separation procedure may be quite simple if a well-done anatomic study using x-ray, ultrasonography, computed tomography (CT) scan, magnetic resonance, and echocardiogram are performed. The precise knowledge of the anatomic variability and physiologic changes of both twins will help the surgeon make decisions like which surgical approach to use and the dissection tactic to be used. The pediatric surgeon also must be aware of the necessity to improvise during the operation.

Invaginacao colo-colica cronica. Apresentacao de um caso. / Chronic colonic intussusception. Report of a case

Os autores apresentam um caso de invaginacao colo-colica-cronica (30 dias), devido a um polipo juvenil do colo descendente. Tecem comentarios sobre a incidencia, quadro clinico, radiologico e tratamento desta patologia