[Videosurgery in infancy and childhood: state of the art. Experience with 1408 procedures in the Instituto da Criança "Pedro de Alcântara"]. / Videocirurgia na criança: estado da arte. Experiência com 1408 procedimentos no Instituto da Criança "Pedro de Alcântara"

The videosurgery in Pediatric Surgery has a large field of applications unfortunately still underexplored. There are few services that routinely use this techinic , and Brazilian articles published are scarce. The Institute of Children's Hospital of the Faculty of Medicine, University of São Paulo, has been using for fifteen years the videosurgery which is now the first choice of treatment, among other diseases as gastroesophageal reflux, the cholecystolithiasis, the nonpalpable undescended testicles and megaesophagus. In this article we report our experience in laparoscopic pediatric surgery, acquired with 1408 surgical procedures, to present this useful method, and beneficial to a large number of situations and still underused in Pediatric Surgery.

Videocirurgia na criança: estado da arte. Experiência com 1408 procedimentos no Instituto da Criança "Pedro de Alcântara" / Videosurgery in infancy and childhood: state of the art. Experience with 1408 procedures in the Instituto da Criança "Pedro de Alcântara"

A videocirurgia em Cirurgia Pediátrica encontra um imenso campo de aplicações ainda, infelizmente, pouco explorado. São poucos os serviços que utilizam rotineiramente essa via de acesso e são escassas as referências nacionais publicadas. O Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr) há uma década e meia a utiliza e hoje a videocirurgia é a via de primeira escolha para tratar, entre outras doenças, o refluxo gastresofagiano, a colecistopatia calculosa, o testículo não palpável e o megaesôfago. Neste artigo relataremos a experiência em videocirurgia pediátrica do ICr, adquirida com 1408 pacientes operados, para divulgar e popularizar esta via de acesso, útil e benéfica para um grande número de situações e ainda subutilizada em Cirurgia Pediátrica.

The videosurgery in Pediatric Surgery has a large field of applications unfortunately still underexplored. There are few services that routinely use this techinic , and Brazilian articles published are scarce. The Institute of Children's Hospital of the Faculty of Medicine, University of São Paulo, has been using for fifteen years the videosurgery which is now the first choice of treatment, among other diseases as gastroesophageal reflux, the cholecystolithiasis, the nonpalpable undescended testicles and megaesophagus. In this article we report our experience in laparoscopic pediatric surgery, acquired with 1408 surgical procedures, to present this useful method, and beneficial to a large number of situations and still underused in Pediatric Surgery.

The role of interleukin-6, endothelins, and apoptotic genes in small bowel transplantation, in a swine model of ischemia and reperfusion injury.

IRI is closely related to sepsis in ITx setting. Complete understanding of the mechanisms involved in IRI development may improve outcomes. Ortothopic ITx without immunosuppression was performed in order to characterize IRI-associated mucosal damage. Twenty pigs underwent ITx. Two groups were assigned to different CI times: G1: 90 min and, G2: 180 min. Euro-Collins was used as preservation solution. Jejunal fragments were collected at donor laparotomy, 30 min, and 3 days after reperfusion. IRI assessment involved: histopathologic analysis, quantification of MPO-positive cells through immunohistochemical studies, quantification of epithelial apoptotic cells using TUNEL staining, and quantification of IL-6, ET-1, Bak, and Bcl-XL genes expression by RT-PCR. Neutrophilic infiltration increased in a similar fashion in both groups, but lasted longer in G2. Apoptosis detected by TUNEL staining increased and anti-apoptotic gene Bcl-XL expression decreased significantly in G1, 3 days after surgery. Endothelin-1 and IL-6 genes expression increased 30 min after the procedure and returned to baseline 3 days after surgery. In conclusion, IL-6 and ET-1 are involved precociously in the development of intestinal IRI. Apoptosis was more frequently detected in G1 grafts by TUNEL-staining and by RT-PCR.

Extrahepatic portal vein thrombosis after umbilical catheterization: is it a good choice for Rex shunt?

BACKGROUND: Extrahepatic portal vein thrombosis (EHPVT) is an important cause of portal hypertension in children. Rex shunt has been used successfully to treat these patients. METHODS: We report our experience in 19 infants and children (5 months to 14 years) with HPVT eligible for a mesenteric-portal surgical shunt with left internal jugular vein autograft. Eight children had idiopathic EHPVT, nine had post-umbilical catheterization EHPVT, one had portal vein agenesis, and one had posttransplant EHPVT. RESULTS: It was possible to perform the Rex shunt in all patients except for 8 of 9 cases in the post-umbilical catheterization EHPVT group. A Warren procedure was performed in 4 of those patients and a proximal splenorenal shunt in 1. Current follow-up ranges from 3 to 26 months. Shunt thrombosis occurred in one patient with portal vein agenesis and associated cardiac anomaly. Portal hypertension has significantly improved after surgery. None of our patients have experienced new bleeding episodes until now. CONCLUSIONS: The Rex shunt should be considered in the treatment of children with idiopathic EHPVT experiencing repeated gastrointestinal bleeding episodes refractory to endoscopic treatment. Nevertheless, the role of this operation for children with post-umbilical catheterization EHPVT is yet to be clearly evaluated.

Malignant tumor of the trachea in children: diagnostic pitfalls and surgical management.

Primary tracheal malignant neoplasms are very rare. Histologically, squamous cell and adenoid cystic carcinomas are the most common types of malignant primary tracheal tumors when all age groups are studied. In the past 5 years, we treated 2 children with tracheal mucoepidermoid carcinoma. Herein we report both cases and review the literature on the subject with particular emphasis on diagnosis and surgical management.

Long-term follow-up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality.

BACKGROUND: Endoscopic sclerotherapy (ES) has been the standard treatment for children with idiopathic extrahepatic portal vein obstruction (EHPVO). Portosystemic shunts are indicated when variceal bleeding cannot be controlled by ES. Recently, mesenteric left portal vein bypass was indicated as a surgical intervention and preventative measure for hepatic dysfunction in children with long-term EHPVO. Nevertheless, there is a lack of published data confirming the extent of hepatic dysfunction, hypersplenism, and physical development in children with long-term follow-up. METHOD: We retrospectively verified the long-term outcomes in 82 children with EHPVO treated with ES protocol, focusing on mortality, control of bleeding, hypersplenism, and consequent hepatic dysfunction. RESULTS: Of the children, 56% were free from bleeding after the initiation of ES. The most frequent cause of rebleeding was gastric varices (30%). Four patients had recurrent bleeding from esophageal varices (4.6%). Four patients underwent surgery as a consequence of uncontrolled gastric varices. There were no deaths. Most patients showed good physical development. We observed a mild but statistically significant drop in factor V motion, as well as leukocyte and platelet count. CONCLUSION: Endoscopic sclerotherapy is an efficient treatment for children with EHPVO. The incidence of rebleeding is low, and there was no mortality. Children develop mild liver dysfunction and hypersplenism with long-term follow-up. Only a few patients manifest symptoms of hypersplenism, portal biliopathy, or liver dysfunction before adolescence.

Intimal dissection of the hepatic artery after thrombectomy as a cause of graft loss in pediatric living-related liver transplantation.

HAT is the main cause of graft loss in pediatric living-related LTx. Revascularization of the graft by thrombectomy and re-anastomosis has been reported to be effective for graft salvage in cases of HAT and should be attempted when potential donors are not available for emergency re-transplantation. Immediate complications secondary to revascularization attempts in cases of HAT are not described. Late complications are mainly related to biliary tree ischemia. We report a case of child who experienced intimal hepatic artery dissection, which extended into intra-hepatic branches of the artery after a thrombectomy with a Fogarty balloon catheter in an attempt to restore arterial flow after HAT. This complication led to acute deterioration of the graft and the need for emergency re-transplantation.

Which is better for esophageal substitution in children, esophagocoloplasty or gastric transposition? A 27-year experience of a single center.

BACKGROUND/PURPOSE: Esophagocoloplasty and gastric transposition are 2 major methods of esophageal substitution in children. The purpose of this study is to review the authors' experience with these 2 techniques and compare the complications of these operations to determine whether 1 method emerges superior to the other. METHODS: A total of 149 children underwent surgery: 115 children underwent esophagocoloplasty, and 34 children underwent gastric transposition. Most patients (113-75.8%) had long-gap esophageal atresia. The operative technique of esophagocoloplasty consisted of the interposition of the transverse colon maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade. Gastric transposition was performed according to classical technique. The transposition of colon and stomach was performed using blunt mediastinal dissection in all patients without thoracotomy. Complications and mortality of the 2 groups of patients were compared. These complications were classified as minor (cervical anastomosis leak, abdominal evisceration, diarrhea, strictures, and reflux to the interposed viscera) and major (necrosis of transposed viscera, dehiscence of an intra-abdominal or intrapleural suture, torsion of transposed viscera, delayed gastric emptying requiring reoperation, and cologastric anastomosis stricture). RESULTS: There were 2 graft necrosis, 1 (0.8%) in the esophagocoloplasty group and another (2.9%) in the gastric transposition group. Patients who underwent esophagocoloplasty experienced a greater incidence of minor complications (P = .001) and less major complications in comparison with the gastric transposition group (P = .001). All minor complications were treatable and had no consequences. No difference was noted between the 2 groups with regard to the mortality rate (0.9% and 5.9%, respectively, P > .05). CONCLUSIONS: Esophagocoloplasty and gastric transposition are satisfactory means of esophageal substitution in children. Considering the incidence of major postoperative complications, esophagocoloplasty must be the first choice for esophageal replacement in children.

The outcome of newborns with abdominal wall defects according to the method of abdominal closure: the experience of a single center.

Recent reports suggest that the technique of abdominal closure in neonates with anterior abdominal wall defects (AWD) correlates with the outcome. The aim of this study is to analyze factors related to mortality and morbidity, according to the technique of abdominal closure of these neonates. Retrospective analysis of charts from 76 consecutive neonates with AWD treated in a single institution. They were divided according to the type of abdominal wall closure: group I: primary closure, group II: silo followed by primary closure and group III: silo followed by polypropylene mesh. Outcome was analyzed separately for neonates with gastroschisis and omphalocele. There were 13 deaths (17.1%). Mortality for neonates with isolated defects was 9.6%. Mortality rate was similar in all groups for either neonates with gastroschisis or omphalocele. Postoperative complications were not significantly different among groups except for a prolonged time of hospitalization in group III. Mortality rate is not correlated with the type of abdominal closure. Neonates with primary closure or with other methods of abdominal wall closure had similar rate of postoperative complications. Neonates with mesh closure of the abdomen have prolonged hospitalization. The use of a polypropylene mesh is a good alternative for neonates whose primary closure or closure after silo placement is not possible.

An exclusively intraabdominal distal esophageal segment prevents primary delayed anastomosis in children with pure esophageal atresia.

PURPOSE: The aim of this study was to evaluate the outcome of children with pure esophageal atresia (EA) managed by the strategy of delayed primary anastomosis and to find parameters to identify which of these children will have satisfactory esophageal growth to permit a successful primary esophageal anastomosis. METHODS: Sixteen children with pure EA were treated by delayed anastomosis strategy from June 1992 to May 2001 at the Instituto da Criança-University of São Paulo Medical School. The treatment consisted of creating an early feeding gastrostomy, continuous upper pouch suction, and periodic radiologic/endoscopic assessments of the gap between the superior and inferior esophageal pouches. The first assessment was done 4 weeks after the initial gastrostomy. Subsequent assessments were done, when necessary, 4 to 10 weeks after the first one. Children with the gap between the pouches corresponding to 2 vertebral bodies or less were considered for primary repair. RESULTS: The waiting period ranged from 8 to 14 weeks. Five children were considered for primary repair (31.3%). All of them had an end-to-end esophageal anastomosis performed without tension. Eleven children (68.7%) did not show significant esophageal growth after the waiting period and were not considered for primary esophageal anastomosis. Eight of them (50%) showed an entirely intraabdominal distal pouch at the first assessment. CONCLUSIONS: (1) Infants with an exclusively intraabdominal distal pouch at the first evaluation will not reach sufficient elongation of the pouches and should be considered early as a candidate for esophageal replacement. (2) Combined radiologic/endoscopic assessment and the measurement of the gap in terms of vertebral bodies is a practical and reliable method to predict the feasibility of primary anastomosis. (3) Using these criteria, primary anastomosis could be accomplished in less than a third of cases.

Circulação extracorpórea por membrana (ECMO) em recém-nascido com insuficiência respiratória por síndrome de aspiração meconial efeitos da administração de surfactante exógeno / Extracorporeal membrane oxygenation (ECMO) in a neonate with respiratory distress due to meconium aspiration syndrome: Effect of the administration of exogenous surfactant

Objetivo: apresentar a evolução clínica de recém-nascido portador de insuficiência respiratória grave neonatal secundária à sindrome de aspiração meconial tratado por circulação extracorpórea por membrana, ou conforme o termo consagrado em língua inglesa, ECMO (Extracorporeal Membrane Oxygenation), o efeito do uso de surfactante exógeno neste caso e os custos do procedimento. Método: descrição de um caso de síndrome de aspiração meconial, tratado na UCINE (Unidade de Cuidados Intensivos Neonatais) do instituto da criança Prof. Pedro Alcantara, Hospital das Clínicas da Universidade de São Paulo. Resultados: o suporte extracorporeo teve a duração de 5 dias, sem complicações clínicas ou mecânicas. Surfactante exógeno de origem porcina foi administrado no 4§ dia, após o quê observamos uma melhora significativa na complacência pulmonar. O recém-nascido pôde então ser rapidamente decanulado. Os custos do tratamento foram compatíveis com a realidade nacional em relação a um recém-nascido criticamente enfermo. Conclusões: a ECMO é indicada em casos de insuficiência respiratória que não respondam a outros tratamentos existentes. Deve ser disponível em Unidades de Tratamento Intensivo (UTIs) neonatais de hospitais terciários e ser empregada conforme critérios bem estabelecidos. A utilização de surfactante exógeno aparentemente antecipou a retirada da ECMO e, portanto, deve ser considerada em casos semelhantes. Os custos do tratamento justificam a organização de Equipes de ECMO nessas UTIs

Metodos de prevencao das alteracoes estruturais pulmonares decorrentes da hernia diafragmatica congenita: estudo experimental com cirurgia fetal / Method of prevention of pulmonary structure alterations derived of congenital diaphragmatic hernia: experimental study with fetal surgery

A hipoplasia pulmonar e causa de obito em 30 a 50 por cento dos recem-nascidos com hernia diafragmatica congenita. O unico metodo de prevenir essa alteracao do desenvolvimento pulmonar e a ligadura traqueal com cirurgia intra-uterina, para permitir o crescimento das vias aereas. Este procedimento foi descrito apenas em animais de experimentacao. O objetivo principal do presente trabalho foi pesquisar um metodo de prevencao da hipoplasia pulmonar, baseado na administracao pre-natal intra-amniotica de drogas, passivel de utilizacao na especie humana...

Atresia do esofago: evolucao do tratamento / Esophageal atresia: evolution of the treatment

Apresenta-se uma atualizacao no diagnostico e tratamento pre e pos operatorio da atresia do esofago, com base no estudo de 45 recem-nascidos tratados no Servico de Cirurgia Pediatrica do Instituto da Crianca "Prof. Pedro de Alcantara", nos ultimos seis anos. Foram analisados o momento do diagnostico, as malformacoes associadas, o numero de casos em que foi necessaria a assistencia ventilatoria, o tipo de suporte nutricional endovenoso, o tempo de preparo pre-operatorio e, finalmente, a finalidade da gastrostomia descompressiva no preparo pre-operatorio...

Abdome agudo na infância por angiostrongilíase intestinal: relato de um caso / Acute abdomen due to intestinal angiostrongylus infections: a case report

É apresentado o caso de uma criança de um ano de idade portadora de abdome agudo causado pelo Angiostrongylus costaricensis. O diagnóstico da angiostrongilíase intetinal é feito apenas através de biópsia e identificaçäo de formas do verme na parede intestinal e/ou mesentério. Ovos e larvas do verme ainda näo säo encontrados nas fezes humanas. Até o momento, a única terapêutica comprovadamente eficaz é a ressecçäo cirúrgica das áreas comprometidas. Devido às limitaçöes diagnósticas, esta enfermidade, provavelmente, tem sua prevalência subestimada. O objetivo do presente artigo é chamar a atençäo para est apossibilidade, em nosso meio, no diagnóstico diferencial do abdome agudo na infância