RESUMO
BACKGROUND: The aim of this study was to assess the 3-year objective and subjective outcomes of patients with complex anorectal fistula treated with Video-Assisted Anal Fistula Treatment (VAAFT). Furthermore, we evaluated the risk factors associated with recurrence. METHODS: All consecutive patients with complex anorectal fistula who underwent VAAFT in Beata Vergine Hospital of Mendrisio, Switzerland, from January 2013 to January 2016, were enrolled. Patients with suspicion or diagnosis of Crohn's disease, malignancy, previous history of radiotherapy or radical pelvic surgery were excluded. Preoperative clinical assessment based upon medical history, physical examination and endosonography, was performed in all patients. Data regarding subjective outcomes (the Patient Global Impression of Improvement, patient satisfaction scores and Wexner score), objective cure rate (absence of fistula at clinical examination), and adverse events were collected during follow-up. Uni and multivariate analysis were performed to investigate outcomes. RESULTS: One hundred and four patients had VAAFT. At 3-year follow-up, 96 patients (92.3%) were available for the evaluation. At 3 years after surgery, 81 of 96 patients (84.4%) declared themselves cured (p = 0.60). Similarly, at 3-year evaluation, 80 of 96 patients (83.3%) were objectively cured (p = 0.52). No serious intraoperative or postoperative complications were reported. All recurrences were treated with a repeat VAAFT procedure resulting in a complete healing. Uni and multivariate analysis of variables potentially involved in the failure of VAAFT showed that age ≥ 50 years was the only factor associated at risk of recurrence. CONCLUSIONS: VAAFT is a highly effective safe procedure for the treatment of anorectal fistula, with a low recurrence rate at 3-year follow-up. However, our study demonstrated that age ≥ 50 years is a risk factor for failure of VAAFT.
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Fístula Retal , Cirurgia Vídeoassistida , Canal Anal , Seguimentos , Humanos , Pessoa de Meia-Idade , Fístula Retal/etiologia , Fístula Retal/cirurgia , Fatores de Risco , Suíça , Resultado do TratamentoRESUMO
AIM: The aim of this study was to evaluate concentrations of erythropoietin (EPO) and vascular endothelial growth factor (VEGF) in serum, aqueous and vitreous humour of diabetic patients with proliferative retinopathy (PDR) and to verify their possible modifications induced by intravitreal injection of bevacizumab (IVB). METHODS: This prospective observational study was performed on patients who underwent vitrectomy for proliferative diabetic retinopathy and macular hole or pucker. The study sample consisted of 33 patients with proliferative diabetic retinopathy and 20 non-diabetic patients with macular hole or pucker. EPO and VEGF levels in serum, aqueous and vitreous humour were measured in both groups. In diabetic patients measures were performed before and after IVB. RESULTS: EPO and VEGF levels in aqueous and vitreous humour were markedly increased in diabetic patients with PDR as compared with those recorded in the control group (P<0.001); contrarily, EPO serum levels were similar in both groups (p=not significant). IVB did not affect EPO levels (aqueous 39.1 ± 29.2 vs. 38.6 ± 26.1; vitreous 179.3 ± 88.3 vs. 131.6 ± 67.8; serum 9.2 ± 5.8 vs. 6.9 ± 3.7 mUI/mL); conversely, VEGF concentration significantly decreased 15 days after IVB in serum and ocular fluids (aqueous 141.6 ± 12.3 vs. 81.4 ± 5.4; vitreous 180.4 ± 45.8 vs. 95.8 ± 23.6; serum 113.9 ± 52.8 vs. 73.2 ± 65.6 mUI/mL). CONCLUSION: These findings demonstrate that the production of VEGF and EPO is regulated by different mechanisms. Intraocular levels of EPO in diabetic patients were significantly higher than those recorded in serum, suggesting a local production. In addition, bevacizumab does not influence intraocular levels of EPO.
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Anticorpos Monoclonais Humanizados/uso terapêutico , Humor Aquoso/química , Retinopatia Diabética/tratamento farmacológico , Eritropoetina/análise , Vitreorretinopatia Proliferativa/tratamento farmacológico , Corpo Vítreo/química , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Bevacizumab , Compartimentos de Líquidos Corporais , Comorbidade , Retinopatia Diabética/metabolismo , Eritropoetina/metabolismo , Feminino , Humanos , Injeções Intravítreas , Edema Macular/etiologia , Edema Macular/metabolismo , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Perfurações Retinianas/metabolismo , Perfurações Retinianas/cirurgia , Soro , Fator A de Crescimento do Endotélio Vascular/análise , Vitrectomia , Vitreorretinopatia Proliferativa/etiologia , Vitreorretinopatia Proliferativa/metabolismo , Hemorragia Vítrea/complicações , Hemorragia Vítrea/cirurgiaRESUMO
We developed a new application of comparative multiplex dosage analysis (CMDA) for evaluation of the ataxin 2 gene. Expansions of the triplet CAG can cause spinocerebellar ataxia type 2 (SCA2), a neurodegenerative disease with an autosomal-dominant mode of inheritance. Molecular diagnosis of SCA2 is routinely based on the use of conventional PCR to detect the CAG expansion. However, PCR does not amplify an allele with an expansion of many triplets (>80), which is typically found in infantile and juvenile forms of SCA2, thus leading to false negatives. We propose the analysis of the ATXN2 gene by CMDA to complement existing methods currently used for the detection of large expansions of the CAG repeat. Using CMDA, the presence of any longer mutated allele in a heterozygous patient or fetus would be inferred due to dosage variation of the very frequent normal allele #22. CMDA can be completed in 1 day, at very low cost, and would be a useful tool for prenatal diagnosis and for diagnosis of presymptomatic forms of early-onset SCA2.
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Dosagem de Genes , Proteínas do Tecido Nervoso/genética , Ataxias Espinocerebelares/genética , Alelos , Ataxinas , Estudos de Casos e Controles , Feminino , Genótipo , Humanos , Masculino , Reação em Cadeia da Polimerase Multiplex/métodos , Ataxias Espinocerebelares/diagnóstico , Expansão das Repetições de TrinucleotídeosRESUMO
Rubinstein-Taybi syndrome is a rare autosomal dominant congenital disorder characterized by postnatal growth retardation, psychomotor developmental delay, skeletal anomalies, peculiar facial morphology, and tumorigenesis. Mutations in the gene encoding the cAMP response element-binding protein (CREB, also known as CREBBP or CBP) on chromosome 16p13.3 have been identified. In addition, some patients with low intelligence quotients and autistic features bear large deletions. Based on these observations, we used multiplex ligation-dependent probe amplification to search for large deletions affecting the CREBBP gene in a Rubinstein-Taybi syndrome patient. We identified a novel heterozygote deletion removing five exons (exons 17-21), encoding the histone acetyltransferase domain. We propose the use of multiplex ligation-dependent probe amplification as a fast, accurate and cheap test for detecting large deletions in the CREBBP gene in the sub-group of Rubinstein-Taybi syndrome patients with low intelligence quotients and autistic features.
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Proteína de Ligação a CREB/genética , Deleção de Genes , Síndrome de Rubinstein-Taybi/genética , Pré-Escolar , Feminino , Testes Genéticos/métodos , Heterozigoto , Humanos , Reação em Cadeia da Polimerase Multiplex , Síndrome de Rubinstein-Taybi/diagnósticoRESUMO
A case report of a primary interstitial ovarian pregnancy is presented. A 37-year-old married woman with two children after two Cesarean sections and a spontaneous abortion, with a contraceptive intrauterine device (IUD) inserted three years before, presented at five weeks plus five days amenorrhea with a positive pregnancy test and lower abdominal pain but with no vaginal bleeding. Her previous menstrual cycles had been regular. She was hemodynamically stable. On bimanual examination, the uterus was of normal size, and there was an approximate four-cm tender right adnexal mass. Serum beta-human chorionic gonadotropin (b-hCG) was confirmed positive. Ultrasound revealed a well-positioned IUD in the uterus and a right adnexal mass with normal vascular flow on Doppler, that contained a well-defined gestational sac, well-distinct from the quiescent hemorrhagic corpus luteum. There was no fetal node or cardiac activity or free fluid. The patient received four injections of methotrexate intramuscularly using the multidose regimen that involves the administration of methotrexate calculated according to body weight, alternated with 0.1 mg/kg of leucovorin calcium per os after 30 hours until the values of 3-hCG had decreased by 15%. The patient's post-treatment period was uneventful with a full restoration of ovarian morphology and the complete absorption of the gestational sac. This case is the first where diagnosis was made by endovaginal sonography and treatment was made by multidose methotrexate. Spiegelberg criteria for the diagnosis of ovarian pregnancy are obsolete; new ultrasound and laboratory criteria are needed for a diagnosis as early as possible without the need of surgery.
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Abortivos/administração & dosagem , Metotrexato/administração & dosagem , Gravidez Ectópica/diagnóstico por imagem , Gravidez Ectópica/tratamento farmacológico , Adulto , Gonadotropina Coriônica Humana Subunidade beta/sangue , Feminino , Humanos , Injeções Intramusculares , Dispositivos Intrauterinos , Leucovorina/administração & dosagem , Gravidez , Gravidez Ectópica/sangue , UltrassonografiaRESUMO
BACKGROUND: Gastrointestinal tract duplications (ATD) are rare malformations that occur with an incidence of 1 in 4000-5000 live births, with heterogeneous clinical pictures in relation to the different location and size. The purpose of this study was to analyze the role of minimally invasive surgery in the management of ATDs, through a critical analysys of 15 years of experience of the Department of Paediatric Surgery, University of Bologna. METHODS: The medical records of 22 children diagnosed with ATDs were retrospectively reviewed (January 1995-August 2010). The study analyses: clinical presentation, preoperative diagnosis, site, anatomic type, treatment, and outcome. RESULTS: Children were 16 males and 6 females, with age ranged from 1 day to 10 years. 20 ATDs (91%) were cystic type, while 2 cases (9%) were tubular one. During the first period of our experience, 10 (45.5%) cases were approached with an open surgery. Then subsequent 8 (36.4%) cases were treated with a diagnostic laparoscopy. This approach permitted also to perform a minilaparotomy, close to the site of the malformation, with a short length of the scar. In 2 cases (9%), we realized an ileal resection with end-to-end anastomosis with a trans-umbilical video-assisted procedure. In 2 cases (9%), we performed a complete removal of the lesions, after complete ligation of the vascular pedicle through a laparoscopic approach. 10 cases (45.5%) were located in the ileum, 6 cases (27.3%) were esophageal duplication, 3 cases (13.6%) were gastric duplications, 2 cases (9%) were located in the colon-rectum. The postoperative course was uneventful in all the cases. DISCUSSIONS AND CONCLUSIONS: this study shows how, in the management of intestinal duplications, a mininvasive approach, is increasingly taking the field, along with increasing the "learning curve" with laparoscopy. In experienced hands, the laparoscopic approach allows an accurate definition of the exact site of duplication and a miniinvasive treatment with similar principles of open techniques.
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Colo/cirurgia , Esôfago/cirurgia , Íleo/cirurgia , Laparoscopia , Reto/cirurgia , Estômago/cirurgia , Cirurgia Vídeoassistida , Anormalidades Múltiplas/epidemiologia , Anormalidades Múltiplas/cirurgia , Algoritmos , Criança , Pré-Escolar , Colo/anormalidades , Anormalidades do Sistema Digestório/epidemiologia , Anormalidades do Sistema Digestório/cirurgia , Esôfago/anormalidades , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Íleo/anormalidades , Incidência , Lactente , Recém-Nascido , Itália/epidemiologia , Laparoscopia/métodos , Masculino , Sistemas Computadorizados de Registros Médicos , Procedimentos Cirúrgicos Minimamente Invasivos , Gravidez , Reto/anormalidades , Estudos Retrospectivos , Estômago/anormalidades , Resultado do Tratamento , Ultrassonografia Pré-Natal , Umbigo/cirurgiaRESUMO
Genital tuberculosis is a bacterial infection still frequent in less developed countries where lots of cases are not diagnosed nor treated. In this work we describe a rare case of primary endometrial tuberculosis in a woman of 50 years old. The diagnosis was confirmed by an ultrasonography of the pelvis and an endometrial biopsy followed by a histological examination. The patient after the diagnosis was put under antiturbecular treatment for six months with complete healing.
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Antituberculosos/uso terapêutico , Endométrio/patologia , Tuberculose dos Genitais Femininos/diagnóstico , Doenças Uterinas/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Tuberculose dos Genitais Femininos/tratamento farmacológico , Doenças Uterinas/tratamento farmacológicoRESUMO
The Authors report a proposal of recommendations concerning Minimally Invasive Surgery (MIS) in Paediatric Oncology. Since the exact role of MIS in Paediatric Oncology is still not completely defined, a restrict panel of Italian Paediatric Surgeons, some interested in Oncologic Surgery, others in MIS, prepared a schematic document, mainly founded on literature data, to provide Paediatric Surgeons with recommendations useful to approach paediatric tumours with MIS. The final draft was approved by the Italian Group of Paediatric Oncologic Surgeons. The Authors summarize the feasibility of MIS, when performed with different purposes (biopsy / resection) and timing (initial / delayed surgery) for the most common solid tumours in children. The oncologic criteria must be always followed with MIS as well as with "open" surgery.
Assuntos
Neoplasias do Córtex Suprarrenal/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias Pulmonares/cirurgia , Linfoma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Neuroblastoma/cirurgia , Neoplasias Ovarianas/cirurgia , Sarcoma/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias do Córtex Suprarrenal/patologia , Biópsia , Criança , Feminino , Humanos , Itália , Neoplasias Pulmonares/secundário , Linfoma/patologia , Masculino , Estadiamento de Neoplasias , Neuroblastoma/patologia , Neoplasias Ovarianas/patologia , Sarcoma/patologia , Neoplasias da Glândula Tireoide/patologiaRESUMO
Spontaneous aneurysms of the ductus arteriosus are rare complications of a patent ductus arteriosus. It is met at any age but it is most commonly seen in children under two months of age. Echocardiography is the best test to diagnose a ductus arteriosus, but actually the role of thoracoscopy is to help in differential diagnosis of mediastinal masses. Surgery should be recommended without delay, to avoid fatal complications, with the resection of the thrombosed aneurysm of the ductus arteriosus.
Assuntos
Canal Arterial , Aneurisma Cardíaco/complicações , Cardiopatias , Trombose , Fatores Etários , Diagnóstico Diferencial , Aneurisma Cardíaco/diagnóstico , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/cirurgia , Cardiopatias/diagnóstico , Cardiopatias/diagnóstico por imagem , Cardiopatias/patologia , Cardiopatias/cirurgia , Humanos , Recém-Nascido , Imageamento por Ressonância Magnética , Masculino , Toracoscopia , Trombose/diagnóstico , Trombose/diagnóstico por imagem , Trombose/patologia , Trombose/cirurgia , Tomografia Computadorizada por Raios XRESUMO
X-ray magnetic circular dichroism (XMCD) and Small Angle Neutron Scattering (SANS) measurements were performed on thiol capped Au nanoparticles (NPs) embedded into polyethylene. An XMCD signal of 0.8 x 10(-4) was found at the Au L3 edge of thiol capped Au NPs embedded in a polyethylene matrix for which Superconducting Quantum Interference Device (SQUID) magnetometry yielded a saturation magnetization, M(S), of 0.06 emu/g(Au). SANS measurements showed that the 3.2 nm average-diameter nanoparticles are 28% polydispersed, but no detectable SANS magnetic signal was found with the resolution and sensitivity accessible with the neutron experiment. A comparison with previous experiments carried out on Au NPs and multilayers, yield to different values between XMCD signals and magnetization measured by SQUID magnetometer. We discuss the origin of those differences.
RESUMO
PURPOSE: The jejunal-ileal atresias are the most common cause of intestinal occlusion in neonatal period and the duodenal atresia is the most common cause of high bowel obstruction in newborn. The treatment classically used is performed by a transverse sovraumbilical laparotomy. The first "minimal-invasive" approach was performed at the end of the years '70. Nowadays three clusters of thought are delineated about of mini-invasive treatment of small bowel atresias: the intestinal continuity can be established with a circumbilical incision, a totally laparoscopic technique or a laparoscopically assisted approach. It's presented our initial experience of bowel atresia in newborn treated with laparoscopically assisted approach. MATERIALS AND METHODS: Three newborns with prenatal diagnosis of suspected bowel obstruction and one with suspected duodenal atresia, confirmed the diagnosis after birth, underwent to laparoscopically-assisted surgery to correct these congenital anomalies. We have treated with this procedure a duodenal atresia, two jejunal atresias and an ileal form. Surgical management was consisted of an explorative laparoscopy that allowed to recognize and isolate the pathological portion. The second step was traditional open surgery: after the exteriorization of the pathological tract through the umbilical wound, we performed the intestinal anastomosis. RESULTS: In all cases the operation was completed successfully, no conversion was necessary. Intraoperatively no complications occurred. The post-operative course was uneventful. CONCLUSION: The video-assisted technique for the correction of small bowel atresia adds the advantages of the classic laparotomic procedure to the laparoscopic ones.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Atresia Intestinal/cirurgia , Laparoscopia , Humanos , Recém-NascidoRESUMO
PURPOSE: Colonic atresia and stenosis are rare causes of intestinal obstruction in the infant. Only 1.8%-15% of intestinal atresias occur in the colon. Congenital colonic stenosis is even less common than colonic atresia. Only 10 cases have been reported in Literature since 1966 and only one late-onset case has been reported in Literature until now. We describe the case of a 4-month-old baby coming to our attention because of an intestinal subocclusion due to a congenital colonic stenosis of the ascending colon. CASE REPORT: A 4-month-old baby came to our attention for persistent abdominal distension, reduction of bowl function and decaying of overall clinical conditions. A plain abdominal radiograph showed distended intestinal loops with air-fluid levels and no gas in the rectum. During the barium enema the contrast medium appeared to completely fill the lumen of the colon up to the ileo-cecal valve and Cecum appearing higher than normal. Beyond the ileo-cecal valve, the contrast medium showed an abnormal hypotonic dilatation of the small intestinal loops. Suspecting an organic intestinal obstruction, an explorative laparotomy was deemed necessary and at halfway in the ascending colon a stenosis was found. RESULTS: The post-operative course was uneventful and the patient is currently in good clinical conditions, has a normal diet and is thriving. CONCLUSION: Considering both the Literature and our own experience, it is wise to reckon the congenital colonic stenosis as a rare but possible cause of complete or partial intestinal obstruction not only in the newborn but also throughout the first year of life.
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Doenças do Colo/congênito , Obstrução Intestinal/congênito , Fatores Etários , Anastomose Cirúrgica , Doenças do Colo/diagnóstico por imagem , Doenças do Colo/cirurgia , Constrição Patológica/congênito , Humanos , Lactente , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/cirurgia , Laparotomia , Masculino , Radiografia Abdominal , Resultado do TratamentoRESUMO
INTRODUCTION: In our clinical context, there are two groups that practice blood purification treatments on acute or chronic liver failure (AoCLF) patients: one group used MARS (molecular adsorbent recirculating system) and the other Prometheus. MATERIALS AND METHODS: The MARS group used the lack of response to standard medical treatment after 72 hours of observation as the access criterion. The Prometheus group used the access criteria of the multicenter Helios protocol for patients in AoCLF, as well as those with primary nonfunction (PNF) and secondary liver insufficiency. Both groups performed treatment sessions of at least 6 hours, which were repeated at least every 24 to 36 hours. RESULTS: The 56 treated AoCLF patients underwent 278 treatment sessions; 41 out of 191 procedures with MARS and 16 out of 87 procedures with prometheus, which was also applied in two cases in PNF and four in secondary liver insufficiency. The results showed that both systems accomplished a good purification efficiency and that application to patients enabled reinstatement on the transplant list and grafts in 70% of the cases with either method. CONCLUSION: Treatment led to recovery in dysfunction among patients not destined for transplantation, achieved with a 48.5% 3-month survival in the MARS group and 33.5% in the Prometheus groups. The treatment results were inversely proportional to the MELD at the time of entry; The treatment appeared to be pointless. Among PNF and secondary liver insufficiency cases.
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Falência Hepática Aguda/terapia , Transplante de Fígado , Desintoxicação por Sorção/métodos , Adulto , Idoso , Transtornos da Coagulação Sanguínea/etiologia , Doença Crônica , Encefalopatia Hepática/prevenção & controle , Humanos , Falência Hepática , Falência Hepática Aguda/sangue , Falência Hepática Aguda/cirurgia , Pessoa de Meia-Idade , Listas de EsperaRESUMO
INTRODUCTION: Congenital cystic lesions of the lung in children are uncommon but potentially life-threatening and warrant an urgent diagnostic work-up. Pulmonary sequestration (PS), congenital cystic adenomatoid malformation (CCAM), congenital lobar emphysema (CLE), and bronchogenic cyst (BC) are the four major congenital cystic lesions, but they share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience with congenital cystic lung disease emphasizing on diagnosis and management. PATIENTS AND METHODS: Between January 1975 and October 2007, 109 patients have been treated, of which 57 males and 52 females, the age ranged from the birth to 13 years. 104 patients presented solitary lesions: CCAM (47), CLE (16), PS (22), BC (19). The remainders 5 patients presented two simultaneous lesions: intralobar PS and CCAM (2), CLE and CCAM (3). RESULTS: All the lesions have been treated surgically: in the first cases, only symptomatic patients underwent surgery, while in the last years, patients have systematically been submitted operated. CONCLUSIONS: A meaningful percentage of CCAM joins to PS and CLE; instead the BC are generally isolated, probably deriving by a more precocious embryogenetic defect. The treatment of these lesions is surgical: CCAM (type I-II) and CLE should be treated promptly in newborns for respiratory distress and pneumothorax; CCAM (type II) and BC generally become symptomatic gradually and expose to degenerative risk; intralobar PS generally becomes symptomatic and surgery prevents the risk of infections. Extralobar PS and the asymptomatic BC are not exempted by surgical approach whenever accidentally described as masses of uncertain nature. Asymptomatic cysts in children should be resected, to avoid later complications of the cysts, which could make operation more difficult. Conservative anatomic resections should be attempted to preserve functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy. In conclusion a correct embryogenetic organization and a clinical evaluation of the congenital cystic lung diseases allow a precocious and effective surgical timing.
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Cisto Broncogênico/diagnóstico , Cisto Broncogênico/cirurgia , Sequestro Broncopulmonar/diagnóstico , Sequestro Broncopulmonar/cirurgia , Malformação Adenomatoide Cística Congênita do Pulmão/diagnóstico , Malformação Adenomatoide Cística Congênita do Pulmão/cirurgia , Cisto Broncogênico/congênito , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pneumonectomia , Enfisema Pulmonar/congênito , Enfisema Pulmonar/diagnóstico , Enfisema Pulmonar/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Torácicos , Resultado do TratamentoRESUMO
BACKGROUND: The Anderson-Hynes pyeloplasty is still the gold standard for the surgical treatment of the ureteropelvic junction obstruction (UPJO) in children. To reduce the surgical invasivity, laparoscopic (RPSc) and retroperitoneoscopic (RPSc) pyeloplasty have been proposed but concerns have been expressed. In the RPSc approach, the small operative space and the technical difficulties have limited the application and diffusion of this techinique while in case of laparoscopy, a transperitoneal technique is used to treat a retroperitoneal disease. We report our initial experience with the "one trocar assisted pyeloplasty" (OTAP) in the treatment of UPJO in children. METHODS: From January 2005 to December 2006 sixteen children (13 males--3 females) from 2 to 18 months of age (mean age 5.6 months), with impaired monolateral renal function underwent surgical treatment for UPJO. In 11 cases the obstruction was on the left side and in one case a crossing vessel was found. The renal pelvis was anteriorly reached using a 10 mm operative telescope via a flank 12 mm incision. The UPJ was exteriorized and a dismembered pyeloplasty performed also for the crossing vessel. In two cases a 6 Fr uretero-pyelo-nephrostomy catheter was used. RESULTS: The patients were discharged after four days without complications. The cosmetic results are excellent. In one case, a small perianastomotic leakage was seen. The ultrasonographic follow-up demonstrated the spontaneous resolution of the leakage. The post operative US follow-up showed the reduction of the dilatation in all cases. DISCUSSION: This is an initial experience and a longer follow-up is needed. However, in our opinion the OTAP could be considered as a safe and feasible alternative to the laparoscopic or retroperitoneoscopic pyeloplasty, especially in very small children and also in presence of crossing vessels.
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Pelve Renal/cirurgia , Laparoscopia , Obstrução Ureteral/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Fatores Etários , Feminino , Seguimentos , Humanos , Hidronefrose/cirurgia , Lactente , Masculino , Diagnóstico Pré-Natal , Espaço Retroperitoneal , Fatores de Tempo , Resultado do Tratamento , Obstrução Ureteral/diagnóstico , Procedimentos Cirúrgicos Urológicos/instrumentaçãoRESUMO
The laparoscopic treatment of benign conditions of the colon represents only one of the numerous application fields of the modern laparoscopic techniques in pediatric surgery. Until the half of the 1990's, the surgical treatment of choice for Hirschsprung's disease has been the procedure ideated by Soave in the early 1960's. Nowadays, the optimal treatment in the classic forms of aganglionic megacolon consists in performing, in neonatal age or in the first months of life, a transanal extramucous pull-through. This approach can be integrated by a laparoscopic step. From September 2000, at the Department of Pediatric Surgery, Bologna University, we have operated 21 cases of congenital aganglionic megacolon with this technique.
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Doença de Hirschsprung/cirurgia , Laparoscopia/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , MasculinoRESUMO
BACKGROUND: Advancements in minimally invasive surgery in newborns have allowed even the most complex neonatal procedures to be approached using these techniques. Other authors have demonstrated its efficacy in the treatment of the esophageal atresia with distal fistula. METHODS: We report our experience based on the thoracoscopic repair of esophageal atresia with distal fistula in two newborns. Birth weights were 2.800 g and 2.300 g respectively. The patients were intubated endotracheally and placed in a left prone position. Four trocars were inserted: the first one of 5 mm was positioned in the fifth intercostal space for the camera, the other two of 3 mm were positioned in the fourth intercostal space on the anterior and posterior axillary line respectively for the operative instruments. The last trocar of 3 mm was inserted in the third intercostal space on the anterior axillary line for the lung retractor. CO2 was insufflated at a pressure of 8 mm Hg and a flow of 0.5 L/min. The fistula was first isolated then ligated and cut with scissors. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 4-0 Vicryl sutures. A tube chest was placed through the lower trocar site with the tip near the anastomosis. RESULTS: These two procedures were free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after a mean of 4 days. Barium swallow made on day 7 demonstrated no leakage and no stenosis of the anastomosis. Total oral feeding was possible after 8 days. Mean hospitalization was 14 days. CONCLUSION: This initial report shows, as demonstrated by the experience since 1999 by other authors, that the thoracoscopic esophageal repair in the newborns is technically feasible and, thanks to a magnified vision, it allows to abtain a good isolation of the esophagus and of the tracheo-esophageal fistula respecting the anatomical structures. Moreover the advantages are in terms of exposure and esophageal length, avoiding the significant short and long-term morbidity associated with thoracotomy.
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Atresia Esofágica/cirurgia , Toracoscopia/métodos , Peso ao Nascer , Nutrição Enteral , Atresia Esofágica/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Masculino , Cuidados Pós-Operatórios , Radiografia Abdominal , Radiografia Torácica , Técnicas de Sutura , Suturas , Fístula Traqueoesofágica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The surgical treatment of biliary atresia is still a great challenge for pediatric surgeons. Kasai's operation usually needs a wide, painful, muscle-cutting laparotomies that quite often are followed by pain and peritoneal adhesion. These possible complications may disturb the post-operative course and humper liver transplantation. Advancements in minimally invasive surgery have allowed even the most complex procedures to be approached using these techniques. METHODS: The authors present a case of successful Roux-en-Y laparoscopic portoenterostomy for the treatment of biliary atresia. We report a case of a 3-month-old patient with biliary atresia who weighted Kg 5,300 at the operation. The patient was placed in supine position. The procedure was performed with 4 trocars of 3 mm and 1 of 10 mm. The umbilical site was used for extracorporeal Roux-en-Y enteroenterostomy. CO2 was insufflated at a pressure of 8 mmHg and a flow of 0.5 L/min. A drain was placed through the lower trocar site with the tip near the anastomosis. RESULTS: The procedure was free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after 2 days. Total oral feeding was possible after 8 days. CONCLUSION: Laparoscopic approach to perform Kasai's operation is technically feasible and thanks to a magnified vision, it allows to abtain a good visualization of the portal structures with an adequate retraction of the liver. This procedure can avoid or decrease the post-operative complications such as pain, breathing difficulty, adhesions and resulting in very small scars. Anyway laparoscopic Kasaiportoenterostomy should be done by a surgeon with a good experience in laparoscopic hand-suturing and neonatal experience and with the support of an experienced in neonatal and infantile videosurgery anaesthesiologist.
Assuntos
Atresia Biliar/cirurgia , Cirurgia Vídeoassistida , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Humanos , Lactente , MasculinoRESUMO
INTRODUCTION: Urethral duplication is a rare and variable malformation of the urinary tract, with non-univocal and complex management. In addition, different classification schemes have been proposed, but none have considered all the possible variants. OBJECTIVE: To report experience with the management of 20 urethral duplication patients and propose a classification of this anomaly. MATERIALS AND METHODS: A retrospective analysis collecting information regarding 20 patients (Table) with urethral duplication treated at a single institution over the past 40 years. Three females and 17 males were treated: two had vesico-urethral duplication, eight had urethral duplication with a single bladder, and eight had 'λ' duplication. RESULTS: Immediate postoperative complications included urethral dehiescence (n = 1) and urethral stenosis (n = 2). The progressive augmentation by dilating the urethra (PADUA) technique was ineffective. During follow-up, the following were recorded: urinary incontinence (n = 2), urinary tract infection (n = 3), hypertension (n = 3) and erectile dysfunction (n = 1). All patients were satisfied with the aesthetic result. DISCUSSION: Urethral duplication is a rare anomaly with male preponderance. Four types of duplication were described, on the basis of anatomy and management: vesical and urethral duplication (type 1), urethral duplication with single bladder (type 2), 'λ-type' duplication (type 3) and 'miscellanea' (multiple urethral channels, spindle urethra, other female forms, type 4). A full description of the malformation and surgical approach was given for each type. The advantages of the classification were compared with the literature. CONCLUSIONS: The proposed classification should be a useful tool, based on the required surgical approach, even if surgery should be tailored to the patient. It is important to restore the anatomy and achieve urinary continence. Surgery can be challenging and a multi-step process, especially in cases of 'λ' duplications.
Assuntos
Uretra/anormalidades , Doenças Uretrais/classificação , Micção/fisiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos Retrospectivos , Inquéritos e Questionários , Doenças Uretrais/congênito , Doenças Uretrais/fisiopatologiaRESUMO
PURPOSE: Acute liver failure (ALF) and acute on chronic liver failure (ACLF) still show a poor prognosis. MARS was used in 22 patients with ALF or ACLF to prolong patient survival for liver function recovery or as a bridge to transplantation. DESIGN: Evaluation of depurative efficiency, biocompatibility, hemodynamics, encephalopathy (HE) and clinical outcome. PROCEDURES: During 71 five-hour sessions we evaluated (0', 60', 120', 180', 240', 300'): bilirubin, ammonia, cholic acid (CCA), chenodeoxycholic acid (CCDCA), leukocytes, platelets, hemoglobin and mean arterial pressure (MAP). Serum creatinine, electrolytes, cardiac output, cardiac index (bioimpedence) and HE (West Haven Criteria score) were evaluated at 0' and 300'. STATISTICAL METHODS AND OUTCOME MEASURES: Student's t-test for pre- vs. end-session values was used. For bilirubin and ammonia the correlation test was made between pre- and end-session values and between pre-session values and removal rates (RRS). MAIN FINDINGS: Survival was 90.9% at 7 days, 40.9% at 30 days. Pre- vs. end-session: bilirubin from 37.2 +/- 12.5 mg/dL to 24.9 +/- 8.9 mg/dL (p < 0.01), ammonia from 88.0 +/- 60.4 micromol/L to 43.6 +/- 32.9 micromol/L (p < 0.01), CCA from 42.8 +/- 21.0 micromol/L 18.2 +/- 9.8 micromol/L (p < 0.01), CCDCA from 26.3 +/- 6.3 micromol/L to 15.7+/-7.6 micromol/L (p<0.01). The correlation test between pre-session values of bilirubin and ammonia vs. RR S was respectively 0.32 (p = 0.01) and 0.30 (p = 0.04). Leukocytes, platelets and hemoglobin remained stable. MAP increased from 82.0 +/- 12.0 mmHg to 87.0 +/- 13.0 mmHg (p < 0.05), West Haven Criteria score decreased from 2.7 +/- 0.7 to 0.7 +/- 0.7 (p < 0.001). CONCLUSION: MARS treatment led in all patients to an improvement of clinical, hemodynamic and neurological conditions, with significant reduction in the hepatic toxins blood level. Treatment biocompatibility and tolerance were satisfactory.