Vocal cord paralysis after cardiovascular surgery in children: incidence, risk factors and diagnostic options.

OBJECTIVES: The aim of this study was to assess the incidence of vocal cord paralysis (VCP) in children after cardiovascular surgery. The secondary aims were to identify the factors potentially associated with VCP and to assess the diagnostic utility of laryngeal ultrasound (US). METHODS: This study is a retrospective review of patients who underwent aortic repair, patent ductus arteriosus ligation and left pulmonary artery surgeries from 2007 to 2017. The following data were collected: patient demographics, gestational age, weight and age at surgery, comorbidities, cardiovascular anomaly and type of procedure, laryngoscopic and US evaluation results. Univariable and multivariable logistic regression models were used to identify the variables associated with VCP. RESULTS: Two hundred and six patients were included in the study. Seventy-two patients (35%) were preterm and 32.5% showed comorbidities. At surgery, median age and weight were 0.6 months [interquartile range (IQR) 0.3-2.1] and 3.0 kg (IQR 1.3-4.0), respectively. Postoperatively, symptomatic patients underwent endoscopic evaluation and VCP was detected in 25 cases (12.1%). Laryngeal US was performed in 8 of these showing an excellent diagnostic relationship. On univariable analysis, factors significantly associated with VCP were prematurity, young age and lower weight at surgery and the presence of comorbidities. The presence of comorbidities and weight at surgery exhibited a significant risk of developing VCP postoperatively on multivariable analysis. CONCLUSIONS: VCP is not an unusual complication of cardiovascular surgery. Certain factors were associated with VCP development but only the presence of comorbidities and weight at surgery were statistically significant on multivariable analysis. Flexible laryngoscopy is the standard diagnostic technique and laryngeal US appears to be a reliable complement.

[How do renal function and dilation change after pieloplasty surgery in children?] / ¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica?

OBJECTIVE: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. METHODS: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (<20%), diminished (20-40%), normal (40-55%) and supranormal (>55%). RESULTS: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (<20%) (mean 9.2+/-8.9) or supranormal (>55%) (mean -8.7+/-8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6+/-2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6+/-2.2) (p<0.0001), except in cases presenting complications. CONCLUSIONS: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty.

OBJETIVO: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros.MÉTODOS: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (<20%), regular (20-40%), normal (40-55%) y supranormal (>55%). RESULTADOS: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala <20% (media 9,2 +/-8,9) o cuando es supranormal >55% (media -8,7+/-8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6+/-2,2). La dilatación renal presentó cambios significativos (p<0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/-1,2), excepto cuando se habían producido complicaciones. CONCLUSIONES: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia.

¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica? / How do renal function and dilation change after pieloplasty surgery in children?

Objetivo: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros. Métodos: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (< 20%), regular (20-40%), normal (40-55%) y supranormal (> 55%). Resultados: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala < 20% (media 9,2 +/-8,9) o cuando es supranormal > 55% (media -8,7 +/- 8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6 +/- 2,2). La dilatación renal presentó cambios significativos (p < 0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/- 1,2), excepto cuando se habían producido complicaciones. Conclusiones: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia

Objective: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. Methods: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (< 20%), diminished (20-40%), normal (40-55%) and supranormal (> 55%). Results: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (< 20%) (mean 9.2 +/- 8.9) or supranormal (> 55%) (mean -8.7 +/- 8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6 +/- 2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6 +/- 2.2) (p < 0.0001), except in cases presenting complications. Conclusions: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty

[Endoscopically treated vesicoureteral reflux: Evolution of the recurrences.] / Evolución de los casos de recidiva del reflujo vesico ureteral resuelto endoscópicamente.

OBJECTIVES: In recent years, different studies have mentioned the recurrence of vesicoureteral reflux (VUR) endoscopically resolved, an exceptional event after open surgery. The aim of this study is to describe the evolution of the cases of recurrence identified in our center to assess the importance of this event. METHOD: We have identified the cases of VUR that recurred after successful endoscopic treatment in our anesdepartment. We have analyzed diagnostic tests, management and final outcome. RESULTS: In our series, we have a 19.5% incidence of VUR recurrence after endoscopic correction. Out of these patients, 66.2% were asymptomatic. Ultrasound (US) showed modifications only in two of the cases. Five of them had worsen differential renal function in the Tc- 99 dimercapto succinyl choline acid scan (DMSA). We performed a new endoscopic procedure in 49 ureteral units with a success rate of 75.5%. CONCLUSIONS: Most patients with VUR recurrence were asymptomatic, with no alterations in US or DMSA scan. Both endoscopic treatment or surveillance might be appropriate in this setting. These data lead us to reckon that the systematic search for VUR relapse in the asymptomatic patient might not be necessary. Similarly, ultrasound or DMSA monitoring should be aimed to the assessment of established reflux nephropathy, regardless of the possibility of recurrence.

Evolución de los casos de recidiva del reflujo vesico ureteral resuelto endoscópicamente / Endoscopically treated vesicoureteral reflux: Evolution of the recurrences

OBJETIVOS: Cada vez más estudios mencionan la incidencia de recidiva del reflujo vesicoureteral (RVU) tratado endoscópicamente, evento excepcional tras cirugía abierta. El objetivo de este trabajo es describir la evolución posterior de los casos identificados en nuestro centro para valorar la importancia de este evento. MÉTODO: Se han analizado los casos de RVU recidivado tras tratamiento endoscópico con éxito en nuestro departamento. Se han revisado pruebas complementarias, manejo posterior y evolución final. RESULTADOS: En nuestra serie, tenemos una incidencia de recidiva del RVU resuelto endoscópicamente del 19,5%. De ellas, 66,2% estaban asintomáticos. La ecografía de control presentaba alteraciones solo en dos de los casos. En cinco de ellos había deterioro de la función renal en el estudio gammagráfico realizado con ácido Tc-99 dimercaptosuccínico (DMSA). Se realizó de nuevo tratamiento endoscópico en 49 unidades con una tasa de éxito del 75,5%. CONCLUSIONES: La mayor parte de los pacientes que presentaron recidiva del RVU se encontraban asintomáticos, sin clínica ni alteraciones en ecografía o DMSA. El tratamiento endoscópico o la observación pueden ser alternativas válidas en estos pacientes. Estos datos nos llevan a replantearnos la búsqueda sistemática de la recidiva en el paciente asintomático. Asimismo, la realización de ecografía o DMSA en el seguimiento es de interés fundamental para la valoración de la nefropatía cicatricial (NC) ya establecida, independientemente de la recidiva

OBJECTIVES: In recent years, different studies have mentioned the recurrence of vesicoureteral reflux (VUR) endoscopically resolved, an exceptional event after open surgery. The aim of this study is to describe the evolution of the cases of recurrence identified in our center to assess the importance of this event. METHOD: We have identified the cases of VUR thatrecurred after successful endoscopic treatment in our department. We have analyzed diagnostic tests, management and final outcome. RESULTS: In our series, we have a 19.5% incidence of VUR recurrence after endoscopic correction. Out of these patients, 66.2% were asymptomatic. Ultrasound (US) showed modifications only in two of the cases. Five of them had worsen differential renal function in the Tc- 99 dimercapto succinyl choline acid scan (DMSA). We performed a new endoscopic procedure in 49 ureteral units with a success rate of 75.5%. CONCLUSIONS: Most patients with VUR recurrence were asymptomatic, with no alterations in US or DMSA scan. Both endoscopic treatment or surveillance might be appropriate in this setting. These data lead us to reckon that the systematic search for VUR relapse in the asymptomatic patient might not be necessary. Similarly, ultrasound or DMSA monitoring should be aimed to the assessment of established reflux nephropathy, regardless of the possibility of recurrence

Laparoendoscopic single-site nephrectomy in children: Is it a good alternative to conventional laparoscopic approach?

BACKGROUND: Minimally invasive surgery is considered to be the gold standard treatment for nephrectomy in children. In recent decades it has been proposed that laparoendoscopic single-site (LESS) surgery is a feasible alternative to perform laparoscopic nephrectomies. OBJECTIVE: The aim of our study was to compare the safety and efficacy of LESS against conventional laparoscopic (CL) nephrectomy. STUDY DESIGN: From March 2010 to November 2012 charts of pediatric patients who underwent laparoscopic nephrectomy at our tertiary center were revised. The data from 23 nephrectomies performed by either LESS or conventional laparoscopic approach were analyzed retrospectively. A transperitoneal approach was selected for both modalities. Indications for surgery included multicystic dysplastic kidneys (MCDK), hydronephrosis, vesicoureteral reflux (VUR), and renal dysplasia. Malignancy and previous abdominal interventions were exclusion criteria. Differences with a p value less than 0.05 were considered to be statistically significant. RESULTS: Twenty-three laparoscopic nephrectomies were performed, 13 by CL (53.5%) and 10 by LESS (46.5%). The mean age of patients was 3.29 ± 3.5 years. There were no significant differences in age, gender, laterality of pathology, size of the kidneys, and surgical indications between the groups (p = 0.067, 0.431, 0.94, 0.644, and 0.078, respectively). The mean operative times were 120 min for LESS and 132.7 min for CL (p = 0.334). No procedures required conversion to open surgery or to standard laparoscopy. There was one intraoperative complication in each group (p = 0.845). The mean length of stay (LOS), narcotic usages, and postoperative complications were similar in both groups. DISCUSSION: To overcome technical difficulties of the LESS approach, articulated tools have been developed. However, they may be not suitable for use with younger children. Although we performed LESS nephrectomies with conventional laparoscopic instruments, in our study, LESS and CL approach were comparable in terms of operative time, analgesic therapy, LOS, and complications. CONCLUSIONS: LESS nephrectomy for benign kidney diseases performed by skilled laparoscopic surgeons is safe and comparable with CL technique in pediatric patients. However, although minimally invasive development pushes towards "a scar-free surgery" (see Figure), these approaches have been performed in only a few centers in the world. Prospective studies comparing both approaches are necessary to verify the advantages of LESS nephrectomy in children.

Endoscopic Treatment of Vesicoureteral Reflux in Infants. Can We Do It and Should We Do It?

OBJECTIVE: To evaluate the outcomes of endoscopic treatment of vesicoureteral reflux (VUR) performed on infants, and to discuss the possible role of this approach in selected cases. MATERIAL AND METHODS: A retrospective analysis was conducted on the patients who underwent endoscopic injection of a bulking substance for VUR in our institution, and a comparison was made with patients treated during infancy and those treated later in life. RESULTS: A total of 463 ureteral units were included (296 children), of whom 47 were patients less than 1 year of age (infants, INF group); the remaining 416 were included in a second group (children, CHL). In this study, the percentage of high-grade VUR and presence of reflux nephropathy were significantly higher in younger patients. Both early failure and recurrence rate were significantly higher in the INF group when compared with the CHL group. No complications were observed in the INF group. CONCLUSION: Endoscopic treatment of VUR is feasible in patients less than 1 year of age. The effectiveness is lower than when patients are treated at a later age but was still over 80% in our series. There were no complications reported related to the procedure itself or to the general anesthesia. Once it is known that endoscopic treatment of VUR can be performed, controversy arises about the indication of treating patients with VUR. Careful selection of VUR cases that are less likely to spontaneously resolve, presence of breakthrough infections, and parental preference, all play a role in the decision-making process.

Isolated tarso-conjunctival superior eyelid traumatic laceration.

To report a unusual case of an isolated traumatic stellated tarso-conjunctival laceration located in the upper left eyelid without eyelid margin involvement and with normal ocular examination. A 19 year-old male wounded by a bokken (wooden katana) while practicing a sham duel had an isolated eyelid tarso-conjunctival laceration, without any other eyelid layer damage, neither skin nor muscle. Treatment was conservative without suture, by means of compressive occlusion fixing the pieces of broken tarsus in the correct position. The aim of the treatment was to avoid any wrong eyelid position secondary to healing. The eyelid maintained normal structure and movement in the follow-up at 8 months. Tarsal plate rupture is usually combined with other eyelid layer damage, which usually requires suture by layers. If eyelid skin and muscle are intact, we may choose conservative management.