Gastric Pneumatosis with Portal Venous Gas can be Treated Non-operatively: A Retrospective Multi-institutional Study.

BACKGROUND: Gastric pneumatosis (GP) is a rare radiologic finding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would benefit most from operative management. METHODS: Between 2010 and 2020, all CT-scan reports in four tertiary centers were searched for the following terms: "gastric pneumatosis," "intramural gastric air" or "emphysematous gastritis." The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions' medical records. RESULTS: Among 58 patients with GP, portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identified the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2 mmol/l, and the absence of gastric dilatation. Multivariable analysis identified the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07-1.79) and the absence of gastric dilatation (OR: 0.07, 95% CI: 0.01-0.79). None of the patients presenting with a baseline lactate rate<2 mmol/l died within 30 days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%). CONCLUSIONS: GP could be managed non-operatively, even in the presence of portal venous gas. However, patients with arterial lactate level>2 mmol/l, or the absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.

The Potential and the Limitations of Esophageal Robotic Surgery in Children.

INTRODUCTION: There have been numerous reports of robotic pediatric surgery in the literature, particularly regarding urological procedures for school-aged children. Thoracic procedures appear to be less common, despite the fact that encouraging results were reported more than 10 years. Our aim was to report a national experience of esophageal robotic-assisted thoracoscopic surgery (ERATS) and to discuss the most appropriate indications. MATERIALS AND METHODS: A retrospective multicenter study was conducted to compile the ERATS performed at five French surgical centers that have been involved in spearheading robotic pediatric surgery over the past 15 years. The data were supplemented by a review of the literature. RESULTS: Over the study period, 68 cases of robotic thoracic surgery were performed at the five pediatric centers in question. ERATS was performed for 18 patients (mean age 7.1 years [ ± 5.6]) in four of the centers. These comprised seven esophageal duplications, four esophageal atresias, five Heller's myotomies, and two cases of esophagoplasty. A conversion was needed for two neonates (11%) due to exposure difficulties. Four other procedures for patients who weighed less than 15 kg were successfully completed without causing postoperative complications. In the past 12 years, 22 other cases of ERATS were published worldwide. The indications were the same, except for esophagoplasty, which was not found. CONCLUSION: Aside from accessibility issues with the robotic platform, the main limitation is still very much that the low body weight of children results in incompatibility between the size of the trocars and the size of the intercostal space. ERATS is clearly a feasible procedure with technical advantages for most pediatric cases with body weights more than 15 kg. A transdiaphragmatic abdominal approach should be considered for lower esophagus surgery.