Barriers to diffusion and implementation of pediatric minimally invasive surgery in Brazil.

BACKGROUND: The main barriers to the broad implementation of pediatric minimally invasive surgery (MIS) are technological, technical, and epistemological barriers, as well as the rarity of certain pathologies. These issues are presumed to be more significant in low- and middle-income countries. This study aimed to identify and analyze the factors limiting the diffusion and implementation of pediatric MIS in Brazil. METHODS: A nationwide cross-sectional survey was conducted via an online questionnaire in Brazil from January 2022 to July 2022. The sample was taken by convenience from the population of pediatric surgeons in Brazil. A total of 187 surgeons were included. The collected data were divided into three sections to evaluate technological, technical, and epistemological limitations to pediatric MIS implementation. RESULTS: Although 85% of the participants had previous training, a lack of adequate training was identified as a significant limiting factor, particularly among those who had taken only short courses (42.3% vs. 64.3%, p = 0.033). Only 14% of the participants reported performing MIS for major pediatric procedures. With respect to intracorporeal suturing, 38.1% of the surgeons with extensive training considered it a limiting factor compared with 60.7% (p = 0.029) of those without prior training. Among those without previous training, 61% cited a lack of financial support or encouragement from their department as the reason. Additionally, 65% of the surgeons considered the lack of basic instruments a limiting factor. Although 95% of the participants agreed that simulation training is indispensable, pediatric surgery fellowship programs in Brazil do not include a standardized curriculum or mandatory training in MIS, and only 47% reported providing training space for their current fellows. CONCLUSION: A combination of technological, technical, and epistemological barriers hinders the implementation of pediatric MIS. Despite its limitations, this study serves as a foundational guide for future analysis and overcoming the identified barriers.

Surgical treatment for severe pediatric tracheobronchomalacia: the 20-year experience of a single center

Abstract Objective: In children with tracheobronchomalacia, surgical management should be reserved for the most severe cases and be specific to the type and location of tracheobronchomalacia. The goal of this study is to describe the presentation and outcomes of children with severe tracheobronchomalacia undergoing surgery. Methods: Retrospective case series of 20 children operated for severe tracheobronchomalacia at a tertiary hospital from 2003 to 2023. Data were collected on symptoms age at diagnosis, associated comorbidities, previous surgery, age at surgery, operative approach, time of follow-up, and outcome. Surgical success was defined as symptom improvement. Results: The most frequent symptoms of severe tracheobronchomalacia were stridor (50 %), cyanosis (50 %), and recurrent respiratory infections (45 %). All patients had one or more underlying conditions, most commonly esophageal atresia (40 %) and prematurity (35 %). Bronchoscopy were performed in all patients. Based on etiology, patients underwent the following procedures: anterior aortopexy (n = 15/75 %), posterior tracheopexy (n = 4/20 %), and/or posterior descending aortopexy (n = 4/20 %). Three patients underwent anterior aortopexy and posterior tracheopexy procedures. After a median follow-up of 12 months, 16 patients (80 %) had improvement in respiratory symptoms. Decannulation was achieved in three (37.5 %) out of eight patients with previous tracheotomy. The presence of dying spells at diagnosis was associated with surgical failure. Conclusions: Isolated or combined surgical procedures improved respiratory symptoms in 80 % of children with severe tracheobronchomalacia. The choice of procedure should be individualized and guided by etiology: anterior aortopexy for anterior compression, posterior tracheopexy for membranous intrusion, and posterior descending aortopexy for left bronchus obstruction.

Surgical treatment for severe pediatric tracheobronchomalacia: the 20-year experience of a single center.

OBJECTIVE: In children with tracheobronchomalacia, surgical management should be reserved for the most severe cases and be specific to the type and location of tracheobronchomalacia. The goal of this study is to describe the presentation and outcomes of children with severe tracheobronchomalacia undergoing surgery. METHODS: Retrospective case series of 20 children operated for severe tracheobronchomalacia at a tertiary hospital from 2003 to 2023. Data were collected on symptoms age at diagnosis, associated comorbidities, previous surgery, age at surgery, operative approach, time of follow-up, and outcome. Surgical success was defined as symptom improvement. RESULTS: The most frequent symptoms of severe tracheobronchomalacia were stridor (50 %), cyanosis (50 %), and recurrent respiratory infections (45 %). All patients had one or more underlying conditions, most commonly esophageal atresia (40 %) and prematurity (35 %). Bronchoscopy were performed in all patients. Based on etiology, patients underwent the following procedures: anterior aortopexy (n = 15/75 %), posterior tracheopexy (n = 4/20 %), and/or posterior descending aortopexy (n = 4/20 %). Three patients underwent anterior aortopexy and posterior tracheopexy procedures. After a median follow-up of 12 months, 16 patients (80 %) had improvement in respiratory symptoms. Decannulation was achieved in three (37.5 %) out of eight patients with previous tracheotomy. The presence of dying spells at diagnosis was associated with surgical failure. CONCLUSIONS: Isolated or combined surgical procedures improved respiratory symptoms in 80 % of children with severe tracheobronchomalacia. The choice of procedure should be individualized and guided by etiology: anterior aortopexy for anterior compression, posterior tracheopexy for membranous intrusion, and posterior descending aortopexy for left bronchus obstruction.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin.

INTRODUCTION: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. METHODS: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. RESULTS: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. CONCLUSION: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin / Onfalocele gigante: Uma nova abordagem para reparo primário no período neonatal utilizando toxina botulínica

ABSTRACT Introduction: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. Methods: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. Results: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. Conclusion: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

RESUMO Introdução: onfalocele gigante (OG) é uma condição complexa para a qual muitas alternativas terapêuticas foram desenvolvidas; no entanto, não há consenso sobre qual o melhor tratamento. Os benefícios e eficácia da toxina botulínica A (TBA) no reparo de grandes defeitos da parede abdominal em adultos foram comprovados, e o relato de uso em crianças cresceu recentemente. O objetivo deste estudo é descrever uma nova técnica para reparo primário de OG utilizando TBA durante o período neonatal e relatar nossa experiência inicial. Métodos: os pacientes foram acompanhados de agosto de 2020 a julho de 2022. A TBA foi aplicada na parede abdominal lateral nos primeiros dias de vida, seguida de correção cirúrgica do defeito abdominal. Resultados: enquanto aguardavam a cirurgia, os pacientes tiveram mínima manipulação, sem ser exigida ventilação mecânica, permaneceram em alimentação enteral plena e mantiveram contato com os pais. A linha média foi aproximada sem tensão e sem necessidade de técnicas adicionais ou uso de prótese. Os pacientes receberam alta com o defeito reparado. Conclusão: essa abordagem representa um meio-termo entre o reparo estagiado e o tratamento não-operatório. Não requer intervenções agressivas no início da vida, permitindo a manutenção do vínculo materno-infantil e a alta do paciente com defeito reparado sem a necessidade de uso de técnicas adicionais ou prótese. Acreditamos que esta técnica deva ser considerada como um novo possível recurso no manejo desta complexa condição.

Avaliação do controle da dor no pós-operatório de cirurgia torácica pelo método visual / Evaluation of pain control in the post-operative period of thoracic surgery using a visual method

Objetivo: Reportar resultados de protocolo específico de tratamento da dor em toracotomia. Métodos: Estudo prospectivo por 12 meses, com acompanhamento de pacientes submetidos à ressecção pulmonar, exceto pneumonectomia. Analgesia foi realizada com cateter peridural e bloqueio intercostal no trans-operatório, morfina e anti-inflamatório no pós-operatório. Durante permanência na sala de recuperação, pacientes foram questionados sobre dor conforme tabela (anexo 1). As perguntas foram realizadas por membros treinados na 6ª, 12ª, 24ª e 48ª horas e no 30º dia de pós-operatório. Resultados: Quarenta pacientes foram incluídos no protocolo. Destes, nenhum sentiu dor insuportável, trinta referiram dor leve e dez referiram dor moderada em 6, 12 e 24 horas. A retirada do dreno alterou a dor (p<0,05). Doze pacientes utilizaram sondagem de alívio, todos masculinos (p<0,05), até o 1º pós-operatório (p<0,001). Houve discreta dor após retirada de dreno. Nenhum paciente referiu dor moderada em 48 horas. Aos 30 dias, 38 pacientes referiram dor mínima e 2 pacientes referiram dor moderada. Não houve mortalidade. Conclusão: Internação em unidade de terapia intensiva pode ser dispensada na maioria das cirurgias torácicas na presença de equipe treinada, e dor pode ser adequadamente tratada sem cateter peridural contínuo. Cuidados invasivos como acesso arterial e venoso profundo não foram necessários, o que reduz custos sem que a recuperação ou dor sejam diferentes do que está descrito na literatura. É absolutamente ético propor este modo de tratamento aos pacientes que não tenham acesso à cirurgia minimamente invasiva(AU)

Objective: To report the results of the specific protocol for treatment of pain in thoracotomy. Methods: A prospective study for 12 months, with follow-up of patients undergoing pulmonary resection, except pneumonectomy. Analgesia was performed with transoperative epidural catheter and intercostal block and postoperative morphine and anti-inflammatory. During stay in the recovery room, patients were asked about pain according to table in Annex 1. The questions were asked by trained members at 6, 12, 24 and 48 hours and 30 days after surgery. Results: Forty patients were included in the protocol. Of these, none felt unbearable pain, thirty reported mild pain and ten reported moderate pain at 6, 12 and 24 hours. Drain removal altered pain (p p <0.05). Twelve patients, all male (p <0.05), used relief probing until the 1st postoperative day (p <0.001). There was a slight pain after drain removal. No patient reported moderate pain within 48 hours. At day 30, 38 patients reported minimal pain and 2 patients reported moderate pain. There was no mortality. Conclusion: Hospitalization in intensive care unit may be waived in most thoracic surgeries in the presence of trained staff, and pain can be properly treated without continuous epidural catheter. Invasive care, such as deep arterial and venous lines, were not needed, which reduces costs without recovery or pain being different from what is described in the literature. It is absolutely ethical to propose this mode of treatment for patients who do not have access to minimally invasive surgery(AU)

Modelo de cuidado analgésico pós-operatório: monitorização pelo método visual em unidade de recuperação / Protocol of postoperative pain control in thoracic surgery using a visual method in recovery room

Objetivo: Reportar resultados de protocolo específico de tratamento da dor em toracotomia. Métodos: Estudo prospectivo por 12 meses, com acompanhamento de pacientes submetidos à ressecção pulmonar. Analgesia foi realizada com cateter peridural e bloqueio intercostal no transoperatório, morfina e anti-inflamatório no pós-operatório. Durante permanência na sala de recuperação, pacientes foram questionados sobre dor conforme tabela (anexo 1). As perguntas foram realizadas por membros treinados na 6ª, 12ª, 24ª e 48ª horas e no 30º dia de pós-operatório. Resultados: Quarenta pacientes foram incluídos no protocolo. Destes, nenhum sentiu dor insuportável, 30 referiram dor leve e 10 referiram dor moderada em 6, 12 e 24 horas. A retirada do dreno alterou a dor (p<0,05). até o 1º pós-operatório (p<0,001) ). Houve discreta dor após retirada de dreno. Nenhum paciente referiu dor moderada em 48 horas. Aos 30 dias, 38 pacientes referiram dor mínima e 2 pacientes referiram dor moderada. Conclusão: Internação em unidade de terapia intensiva pode ser dispensada na maioria das cirurgias torá- cicas na presença de equipe treinada e dor pode ser adequadamente tratada sem cateter peridural contínuo. Cuidados invasivos como acesso arterial e venoso profundo não foram necessários, o que reduz custos sem que a recuperação ou dor sejam diferentes do que está descrito na literatura. É absolutamente ético propor este modo de tratamento aos pacientes que não tenham acesso à cirurgia minimamente invasiva. Comparação de custos no nosso meio entre cirurgia por vídeo e aberta deve ser melhor estudada(AU)

Aim: To report the results of a specific pain management protocol in thoracotomy. Methods: A prospective study for 12 months, with follow-up of patients undergoing pulmonary resection. Analgesia was performed with epidural catheter and intercostal block intraoperatively, and morphine and anti-inflammatory postoperatively. During stay in recovery room, patients were asked about pain according to a table (Annex 1). Trained members asked questions at 6, 12, 24 and 48 hours and at 30 days after surgery. Results: Forty patients were included in the protocol. Of these, none felt unbearable pain, thirty reported mild pain and ten reported moderate pain at 6, 12 and 24 hours. Drain removal altered the pain (p<0,05) , até o 1º pós-operatório (p<0.001). There was slight pain after drain withdrawal. No patient reported moderate pain at 48 hours. At day 30, 38 patients reported minimal pain and two patients reported moderate pain. Conclusion: Hospitalization in intensive care unit may be waived in most thoracic surgeries in the presence of trained staff and pain can be properly managed without continuous epidural catheter. Invasive care procedures such as deep arterial and venous access were not needed, which reduces costs without recovery or pain being different from what is described in the literature. It is absolutely ethical to propose this mode of treatment for patients who do not have access to minimally invasive surgery. Cost comparisons in our community between open and video surgery should be further studied(AU)