Shock séptico: complicación atípica de duplicación del tracto alimentario / Septic shock: an atypical complication of alimentary tract duplication

Las duplicaciones del tracto alimentario son un conjunto heterogéneo de anomalías congénitas del tubo digestivo. Su forma de presentación es variada, y pueden desarrollar distintas complicaciones libradas a su evolución natural. La infección es una complicación poco frecuente, pero que no puede desconocerse por la gravedad que implica. Se presenta el caso de una paciente de 2 años de edad, previamente sana, con una complicación atípica de una duplicación del tracto alimentario: un shock séptico. Consultó inicialmente por distensión y dolor abdominal asociado a una masa abdominal palpable. Los estudios imagenológicos evidenciaron una formación líquida parcialmente tabicada en el hemiabdomen derecho. Durante la internación, se presentó una infección intratumoral, que evolucionó al shock séptico. Respondió favorablemente al tratamiento médico del shock, y se realizó la exéresis quirúrgica posteriormente. La anatomía patológica confirmó la duplicación del tracto alimentario.

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Septic shock: an atypical complication of alimentary tract duplication. / Shock séptico: complicación atípica de duplicación del tracto alimentario.

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Las duplicaciones del tracto alimentario son un conjunto heterogéneo de anomalías congénitas del tubo digestivo. Su forma de presentación es variada, y pueden desarrollar distintas complicaciones libradas a su evolución natural. La infección es una complicación poco frecuente, pero que no puede desconocerse por la gravedad que implica. Se presenta el caso de una paciente de 2 años de edad, previamente sana, con una complicación atípica de una duplicación del tracto alimentario: un shock séptico. Consultó inicialmente por distensión y dolor abdominal asociado a una masa abdominal palpable. Los estudios imagenológicos evidenciaron una formación líquida parcialmente tabicada en el hemiabdomen derecho. Durante la internación, se presentó una infección intratumoral, que evolucionó al shock séptico. Respondió favorablemente al tratamiento médico del shock, y se realizó la exéresis quirúrgica posteriormente. La anatomía patológica confirmó la duplicación del tracto alimentario.

Lessons Learned After 101 Cases of Single-Site Magnetic-Assisted Cholecystectomy in Children.

BACKGROUND / PURPOSE: The aim of this report is to present our experience with a magnetic-assisted single-site cholecystectomy technique ("magnachole") in pediatric patients. METHODS: We performed a retrospective chart review of all patients who underwent magnachole between 2009 and 2019. We evaluated patients' demographics, diagnosis, operative time, complications, conversion rate and length of stay. Additionally, simple lineal regression analysis was conducted to determine if the surgeon's experience, the patient's age at surgery, the patient's gender or the patient's body weight affected operative time. RESULTS: A total of 101 patients were operated during the analyzed period. The mean age at surgery was 12.6 (range 4 to 19) years, and the mean body weight was 53.7 (range 13.5 to 123) kg. The most frequent indication (91%) was symptomatic cholelithiasis. Mean operative time was 85 (range 45 to 240) min. The mean operative time decreased by 22.7 min (p < 0.001, 95% [CI] 10.35 to 35.13) when we compared the first 51 cases to the last 50 cases. Simple lineal regression showed a reduction of 2.6 min in operative time per year. Age at surgery, gender, and weight did not influence operative time. There were no intraoperative complications. Only 1 case required an additional port to complete the operation. There were no conversions to open cholecystectomy. Median length of stay was 26 h (range 10 to 168). CONCLUSION: The magnachole technique is safe and effective, and has become our preferred surgical approach for children who need a cholecystectomy. As expected, the operative time decreased as surgeons gain experience with the technique. The technique is feasible regardless of the patient's body habitus. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level IV.

Changes in chest compression indexes with breathing underestimate surgical candidacy in patients with pectus excavatum: a computed tomography pilot study.

BACKGROUND: Haller Index (HI) ≥3.25 by computed tomography (CT) at end-inspiration has been used to indicate surgical correction in patients with pectus excavatum. However, chest wall diameters vary with breathing and may modify HI values and surgical indications. The aim of our study was to report the changes in HI with breathing and their impact in the surgical indication rates. METHODS: Thirty six patients with pectus excavatum underwent chest CT evaluation at both end-inspiration and end-expiration. HI was derived by dividing the transverse diameter (TD) of the chest by the anteroposterior diameter (APD). Cardiac compression index (CCI) was then calculated by dividing the cardiac TD by the APD. RESULTS: Mean patient age was 19 ± 7 years old and 86.8% were males. From end-inspiration to end-expiration, large changes in APD values corresponded to large changes (29.6%) in HI values. CCI increased significantly during end-expiration, primarily driven by an increase on the cardiac TD. Surgical indication was found in 71% and 91% of patients during end-inspiration and end-expiration, respectively (p<0.05). CONCLUSIONS: This study showed that the severity indexes of the pectus excavatum were all significantly more severe at end-expiration than at end-inspiration, leading to an increase in surgical candidacy. We therefore recommend performing the CT at end-expiration.

Novel hybrid (magnet plus curve grasper) technique during transumbilical cholecystectomy: initial experience of a promising approach.

OBJECTIVES: The use of magnets in transumbilical cholecystectomy (TUC) improves triangulation and achieves an optimal critical view. Nonetheless, the tendency of the magnets to collide hinders the process. In order to simplify the surgical technique, we developed a hybrid model with a single magnet and a curved grasper. PATIENTS AND METHODS: All TUCs performed with a hybrid strategy in our pediatric population between September 2009 and July 2012 were retrospectively reviewed. Of 260 surgical procedures in which at least one magnet was used, 87 were TUCs. Of those, 62 were hybrid: 33 in adults and 29 in pediatric patients. The technique combines a magnet and a curved grasper. Through a transumbilical incision, we placed a 12-mm trocar and another flexible 5-mm trocar. The laparoscope with the working channel used the 12-mm trocar. The magnetic grasper was introduced to the abdominal cavity using the working channel to provide cephalic retraction of the gallbladder fundus. Across the flexible trocar, the assistant manipulated the curved grasper to mobilize the infundibulum. The surgeon operated through the working channel of the laparoscope. RESULTS: In this pediatric population, the mean age was 14 years (range, 4-17 years), and mean weight was 50 kg (range, 18-90 kg); 65% were girls. Mean operative time was 62 minutes. All procedures achieved a critical view of safety with no instrumental collision. There were no intraoperative or postoperative complications. The hospital stay was 1.4±0.6 days, and the median follow-up was 201 days. CONCLUSIONS: A hybrid technique, combining magnets and a curved grasper, simplifies transumbilical surgery. It seems feasible and safe for TUC and potentially reproducible.

Initial experience with magnet-assisted single trocar appendectomy in children.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is increasingly being used to treat acute appendicitis. Existing SILS techniques suffer from inefficient triangulation and poor ergonomics. In an effort to improve on existing SILS techniques, we developed the magnet-assisted single trocar (MAST) appendectomy. SUBJECTS AND METHODS: We retrospectively analyzed all MAST appendectomies performed between March 2010 and February 2011. Outcomes included demographics, diagnosis, operative time, hospital stay, and complications. RESULTS: Twenty-three MAST appendectomies were performed in 10 boys and 13 girls. The mean age at operation was 12.22 years (range, 5-19 years), and the mean weight was 46.5 kg (range, 25-82 kg). At presentation the mean white blood cell count was 15,000 with 74% polymorphonuclear neutrophils. The mean operative time was 61 minutes (range, 20-105 minutes), and length of stay was 3.6 days (range, 1-7 days). In total, 4 operations (17%) required one additional 5-mm trocar to complete the operation, and none was converted to an open operation. There were no intraoperative complications, nor were there any wound infections. CONCLUSIONS: MAST appendectomy is safe and effective in children. Magnetic instruments provide excellent triangulation and improve ergonomics. This technique uses a single 12-mm trocar and can be performed without the aid of a surgical assistant.

A simple way to fix a trocar during pediatric laparoscopy.

We introduce a simple method of fixing trocars to the abdominal wall in children. After the trocar is inserted into the abdominal wall, we place a 2/0 silk suture through the skin next to the trocar, then a sterile Nylon 6.6 plastic seal (Sumar Inc, Buenos Aires, Argentina) is wrapped around the trocar and the end of one of the sutures. Lastly, both suture ends are tied around the plastic seal. To further ease and speed the procedure, we recently introduced a plastic seal fastening device. This method is simple, fast, efficacious, and inexpensive and can be used with all trocar sizes.

[Thoracoscopic lung lobectomy: preliminary results in pediatric patients]. / Lobulectomía pulmonar toracoscópica: resultados iniciales en pediatría.

The objective of the present study consists of revising our initial experience with the use of thoracoscopic surgery for lung resections and their complications. Clinical histories and videos, from patients treated surgically at the Fundación Hospitalaria-Private Children Hospital and CEMIC Universitary Hospital from april 2005 to october 2008, were retrospectivelly estudied. Eleven female and 9 male patients were included. The median surgical time was 150 min (range: 60-270 min). The median time of chest tube permanence was 3 days (range: 2-10 days). Median hospital stay was 15 days (range: 3-29 days). It was concluded that thoracoscopic lung lobectomies are technically feasible and applicable to all paediatric ages; they should be considered as an alternative approach for trained groups.

Lobulectomía pulmonar toracoscópica: resultados iniciales en pediatría / Thoracoscopic lung lobectomy: preliminary results in pediatric patients

El objetivo del presente estudio consistió en revisar nuestra experienciainicial con el uso de la toracoscopia para la realización de resecciones pulmonares y sus complicaciones. Para ello se llevó a cabo un estudio retrospectivo de las historias clínicas y videos de lobulectomías pulmonares toracoscópicas de pacientes intervenidosquirúrgicamente en la Fundación Hospitalaria-Hospital Privado de Niños y en el Hospital Universitario CEMIC durante el período 04/2005 - 10/2008. Se incluyeron 11 pacientes delsexo femenino y 9 del sexo masculino. Las medianas del tiempo quirúrgico, del tiempo de permanencia del tubo de drenaje y de la estadía hospitalaria fueron de 150 minutos (intervalo:60-270 minutos), 3 días (intervalo: 2-10 días) y 15 días (intervalo: 3-29 días), respectivamente. Se concluyó finalmente que la lobulectomía pulmonar toracoscópica es una técnica factible yaplicable a todas las edades pediátricas, que debiera considerarse como alternativa de abordaje para grupos entrenados.

Lobulectomía pulmonar toracoscópica: resultados iniciales en pediatría / Thoracoscopic lung lobectomy: preliminary results in pediatric patients

El objetivo del presente estudio consistió en revisar nuestra experienciainicial con el uso de la toracoscopia para la realización de resecciones pulmonares y sus complicaciones. Para ello se llevó a cabo un estudio retrospectivo de las historias clínicas y videos de lobulectomías pulmonares toracoscópicas de pacientes intervenidosquirúrgicamente en la Fundación Hospitalaria-Hospital Privado de Niños y en el Hospital Universitario CEMIC durante el período 04/2005 - 10/2008. Se incluyeron 11 pacientes delsexo femenino y 9 del sexo masculino. Las medianas del tiempo quirúrgico, del tiempo de permanencia del tubo de drenaje y de la estadía hospitalaria fueron de 150 minutos (intervalo:60-270 minutos), 3 días (intervalo: 2-10 días) y 15 días (intervalo: 3-29 días), respectivamente. Se concluyó finalmente que la lobulectomía pulmonar toracoscópica es una técnica factible yaplicable a todas las edades pediátricas, que debiera considerarse como alternativa de abordaje para grupos entrenados.(AU)

Which is the best vessel-sealing method for pediatric thoracoscopic lobectomy?

INTRODUCTION: The general aim of this report was to determine how a vascular accident (VA) or vascular incident (VI) could be prevented and controlled during thoracoscopic lung lobectomies (TLLs). MATERIALS AND METHODS: Clinical records and videos of patients (n:21) who underwent a programmed TLL during a 3-year period at the Private Children's Hospital "Fundación Hospitalaria" and CEMIC University Hospital (Buenos Aires, Argentina) were reviewed retrospectively. A VA was defined as the accidental bleeding during dissection, depending on the surgeon and/or inflammatory conditions, adhesions, and so on. A VI was defined as the unexpected bleeding after successful vascular sealing, depending on the vascular-sealing device. The conversion criteria to thoracotomy were uncontrollable VA or VI, limited visibility, difficult dissection, and other. RESULTS: There were no VA, but there was a 24% rate of VI (n:5). All the VI were arterial, not venous. All the VI were observed in children older than 7 years of age because of deficient sealing. All of them were successfully controlled with LigaSure() (Valleylab, Boulder, CO) and/or one proximal Hem-o-Lok((R)) clip (Weck Closure Systems, Research Triangle Park, NC) without conversion. Conversion was due to limited visibility (n:2) or difficult dissection (n:2) of the diseased lobe. CONCLUSIONS: Based on our early experience and a review of the literature, we believe TLL is a feasible and technically reproducible approach that avoids the inherent morbidity of a major thoracotomy incision. Bleeding should not be the main argument to decide in favor of a thoracotomy. LigaSure's reliability would depend on vascular diameter and on patient age. VIs can be prevented in older children by using the sealing device and a proximal Hem-o-Lok clip.