RESUMO
The first cases of atresia or web in the pyloric and prepyloric regions were described in the literature since 1937. To date, only one case of atresia at the junction between the fundus and the body of the stomach has been reported. We want to describe a complex case with incomplete atresia between fundus and gastric body, with left lateral diaphragmatic hernia, treated in several stages by endoscopic, open surgery and minimally invasive surgery
Assuntos
Gastrectomia , Refluxo Gastroesofágico/cirurgia , Hérnia Diafragmática/cirurgia , Laparoscopia , Estômago/anormalidades , Estômago/cirurgia , Diagnóstico Diferencial , Procedimentos Cirúrgicos do Sistema Digestório , Feminino , Humanos , Lactente , Doenças Raras , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: Imperforate anus represents a wide spectrum of anorectal malformations associated with urologic, neurologic and orthopedic malformations. The outcome from the various corrective measures has improved due to new surgical techniques as well as to a better understanding of the pathology. Other factors which influence the overall outcome include the degree of patient acceptance, family support as well as the ability of the health care structure to support the patient's needs on a clinical, functional and psychologic level. AIM OF THE STUDY: Assess (with the new techniques available) the quality of life in the adult patient with ARM and compare it to that experienced by a younger patient; also we wish to determine the correlation between the observed abnormalities with the functional, neurologic and urologic outcome. MATERIALS & METHODS: Sixty-six patients were subjected to PSARP (36 M; 30 F). Six presented with cloaca and 60 with ARM (23 high and 37 low). All patients underwent the same workup to include L/S MRI diagnostics, evaluation for incontinence (urinary and bowel), a urology screening, and if required, a subsequent urodynamic study with rehabilitation and/or bowel management. All answered questionnaires (AIMAR: Italian parent's association of ARM) in order to assess their satisfaction with the current health condition, with the information received and with the treatment and follow-up sessions. The patients were classified into one of two groups. Group A, totaled 33 patients (4 cloacae) with an age range between 2 and 12 years who were operated after 1995. The second, group B, was made up of 33 patients who had been surgically treated before 1995 (age range 15-41 years), had followed the study protocol and had also a neuropsychiatry consult. RESULTS: Overall fecal continence was 69% and of this number 37% were clean without constipation. Twe2nty-one patients (32%) suffered from some form of constipation. Constipation was the most common functional disorder observed in patients who have undergone PSARP. The highest incidence of constipation was found in the ARM (low type), a favorable prognostic group with 43% constipation. Patient with "high" defects and a cloaca had a lower incidence of constipation (18%). Of the 59 patients evaluated, 85% were urinary continent and 15% were incontinent. All of the incontinent patients were in the unfavorable prognostic group of malformations. Urodynamic studies showed 7 neurogenic bladders (NB) and 2 patients with a neurovescical dysfunction (NVD). Of the 50 "dry" patients. 20 had voiding disturbances due to a voiding dysfunction, in the absence of neurologic abnormalities, and presented occasional daytime or nighttime wetting. There was no correlation between the level of the anatomic defect and the urodynamic patterns in the group. Abnormal MRI findings were observed in thirty out of fifty-two patients evaluated. The MRI findings were classified as follows. Severe abnormalities: 7 patients (13%) presented with a combination of skeletal (sacral/lumbar) and spinal cord anomalies. Only spinal cord abnormalities: 12 patients (21%). Only skeletal abnormalities: 11 (19%) patients. Patients were divided into high, low and cloacal malformations. A high degree of statistical correlation was noted between the patients belonging to the cloacae and high defect groups and the abnormal MRI findings. No significant correlation was found between the low defect group and dysrafism, abnormal MRI results and the severity of the malformation. The incidence of Tethered Cord (TC) in our limited number of patients was limited in our study (9% in the high and 7% in the low defect group) when compared to the current literature. Furthermore there was no statistically conclusive evidence that TC by itself affects the urinary or fecal control in our patients. Our recommendation is nevertheless to obtain an MRI study in all patients with ARM. CONCLUSION: All patients 17 and older reported a "good quality of life". Four are married, two with children. Aclose working relationship with the medical personnel is not only necessary but is also well received by the family particularly when younger patients are involved. The adult patient easily adapts even when information is initially scarce. He quickly reaches autonomy with personalized solutions but prefers a longer follow-up time during which, specialized medical facilities will play an important role in the treatment of ARM. Our findings illustrate the importance of both global disease-specific functioning and perceived psychosocial competencies for enhancing the QL of these patients.
Assuntos
Anormalidades Múltiplas , Canal Anal/anormalidades , Canal Anal/fisiopatologia , Qualidade de Vida , Reto/anormalidades , Reto/fisiopatologia , Anormalidades Múltiplas/fisiopatologia , Anormalidades Múltiplas/cirurgia , Adolescente , Adulto , Canal Anal/cirurgia , Criança , Pré-Escolar , Constipação Intestinal/etiologia , Incontinência Fecal/etiologia , Incontinência Fecal/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Reto/cirurgia , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento , Incontinência Urinária/etiologia , Incontinência Urinária/fisiopatologia , UrodinâmicaRESUMO
Gallbladder polypoid lesions are rare in the pediatric patient and sometimes represent an incidental finding. A 13 year old male was referred to the Padua Hospital Pediatric Department for an obesity. A routine abdominal ultrasound (US) detected a gallbladder polypoid lesion 6 mm in diameter, initially considered a gallbladder adenoma. Investigation did not detect any other biliary tract abnormality. After seven months, the asymptomatic patient underwent a follow-up US which revealed the disappearance of the polypoid mass. The following concerns are raised: what is the size of the polypoid mass that should be considered for surgery? How does the presence of symptoms worsen the diagnosis and lead to preferring a surgical approach (cholecystectomy) over an echographic follow-up?
Assuntos
Doenças da Vesícula Biliar/diagnóstico , Pólipos/diagnóstico , Adolescente , Adulto , Diagnóstico Diferencial , Seguimentos , Doenças da Vesícula Biliar/diagnóstico por imagem , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/diagnóstico por imagem , Humanos , Masculino , Pólipos/diagnóstico por imagem , Radiografia Abdominal , Remissão Espontânea , Fatores de Tempo , UltrassonografiaRESUMO
Animal bite lesions in the pediatric patient are mainly accounted for by dog bites in 80% to 90% of the cases. They often present a favorable prognosis but serious lesions do account for 5% to 20% of the total incidence. We will present three particular clinical cases which required urgent surgical treatment as well as a review of the current literature to include both medical and surgical treatment methods for this kind of lesion.
Assuntos
Mordeduras e Picadas/cirurgia , Cães , Animais , Criança , Pré-Escolar , Humanos , Lactente , Escala de Gravidade do Ferimento , MasculinoRESUMO
The authors reports their experience on 248 patients affected by minctional disorders isolated or related to UTI (upper tract infections) and VUR (vesico-ureteral reflux). All the patients were assessed throught a predominantly non invasive diagnostic approach which included: pediatric urologic examination with aimed anamnestic and clinical freaming, functional examination of the lower urinary tract using uroflowmetry + EMG of the perineal plane muscles (UR + EMG), kidney and bladder ultrasound. This methodology has permitted a widening of the indications in the study of vesical function as well as limiting the selected cases (hight UTI, uncertain diagnosis) of mini-invasive examination, such as flow pressure study, minctional cystourethrogram (MC) and or renal scintigraphy. An MNR of the lumbo-sacral medulla (cord) and a neurological and/or neurosurgery evaluation were only carried out were there was a suspected occult neurological pathology. The clinical sintomatogy was as follows: approximately 70% of the patients suffered from partial diurnal incontinence, 42% were affected by secondary nocturnal enuresis while 58.6% suffered from recurrent UTI. In those patients with UTI, 11% (16 patients, 24 ureteral units) suffered from associated VUR while 3.5% suffered from either congenital or acquired urethral stenosis. From the urodynamic examination, we determined the presence of detrusorial instability in 158 patients (64%) and lazy bladder or vescical hypotonia in 84 patients (34%). The suggested therapy foresees the use of: hospital home-based uroriabilitation (minctional biofeedback), endoscopic therapy (sub-ureteral bulking, urethral dilatation) and corrective VUR surgery (only in those cases that did not respond to medical treatment). The percentage of total recovery in patients with detrusorial instability was 80%, the minctional biofeedback both associated and unassociated with drug therapy lead to complete recovery in 66% of patients with lazy and uncordinated bladder, wile 26% showed improvement and 7 patients (8.4%) did not respond. All the patients with VUR (24 reflux units) recovered; and endoscopic therapy and or surgery (12 reflux units) was carried out in some of this patients.
Assuntos
Retenção Urinária/diagnóstico , Retenção Urinária/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Retenção Urinária/etiologia , Infecções Urinárias/complicações , Urodinâmica/fisiologia , Refluxo Vesicoureteral/complicações , Refluxo Vesicoureteral/cirurgiaRESUMO
PURPOSE: We evaluate the results of an elective cardiopulmonary bypass conceived to minimize the surgical risk related to its use with temporary circulatory arrest and deep hypothermia in the treatment of patients with renal tumor extending into the right atrium. MATERIALS AND METHODS: From July 1996 to December 2000, 19 patients with renal neoplasm and venous involvement were admitted to our department. Three patients 4, 57 and 58 years old with a right (2) and left (1) renal tumor extending into the right atrium underwent radical nephrectomy and tumor thrombus removal using a normothermic cardiopulmonary bypass. The bypass circuit was connected with a vacuum assisted venous drainage giving a negative pressure of 20 to 40 mm. Hg. Neither circulatory arrest nor hypothermia was used. Tumor thrombus was extracted through a longitudinal "cavotomy" and removed along with the kidney. RESULTS: Total cardiopulmonary bypass time was 14, 19 and 22 minutes, respectively. No intraoperative or postoperative complications due to surgical technique occurred. No significant bleeding was observed at the time of cavotomy and all neoplastic tissue was removed. Pathological examination documented renal cell carcinoma in 2 cases and Wilms tumor in 1. All the patients are alive 30, 42 and 15 months, respectively, after the operation. CONCLUSIONS: Normothermic cardiopulmonary bypass with vacuum assisted venous drainage makes circulatory arrest and hypothermia unnecessary and avoids the potential complications associated with these procedures. With respect to veno-venous shunts this technique guarantees complete surgical control of the thrombus and avoids the need for extensive dissection of the retrohepatic vena cava and Pringle maneuver.
Assuntos
Ponte Cardiopulmonar/métodos , Neoplasias Cardíacas/cirurgia , Neoplasias Renais/cirurgia , Pré-Escolar , Átrios do Coração , Neoplasias Cardíacas/patologia , Humanos , Neoplasias Renais/patologia , Pessoa de Meia-Idade , Invasividade Neoplásica , Células Neoplásicas Circulantes , Veia Cava Inferior/patologia , Veia Cava Inferior/cirurgiaRESUMO
OBJECTIVE: To address reasons for diagnostic failure in children with coexisting pelviureteral and vesicoureteral junction obstruction. PATIENTS AND METHODS: A total of 11 children with coexisting pelviureteral and vesicoureteral junction obstruction are reported. This anomaly was recognised at presentation in only 5 (45%) of cases. In the remainder, correct diagnosis was made after initial pyeloplasty and a significant delay occurred in 3 children. In all 11 patients treatment consisted of pyeloplasty and subsequent reimplantation. RESULTS: A satisfactory postoperative course with improvement of urinary tract dilatation was noted in all 11 patients, while 8 of 11 patients showed preserved renal function at late follow-up. CONCLUSION: According to the few available data, our data confirm the difficulty of diagnosing coexisting pelviureteral and vesicoureteral junction obstruction in children. However, prompt recognition and relief of urinary obstruction in these patients is mandatory in order to prevent deterioration of renal function.
Assuntos
Nefropatias/complicações , Pelve Renal , Obstrução Ureteral/complicações , Doenças da Bexiga Urinária/complicações , Dilatação Patológica , Doenças Fetais/etiologia , Taxa de Filtração Glomerular , Humanos , Hidronefrose/etiologia , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Pelve Renal/cirurgia , Ureter/patologia , Ureter/cirurgia , Obstrução Ureteral/diagnóstico , Obstrução Ureteral/fisiopatologia , Doenças da Bexiga Urinária/diagnóstico , Doenças da Bexiga Urinária/fisiopatologiaRESUMO
Blunt abdominal trauma is the most common cause of pancreatic injuries in children. Non-operative management of traumatic injuries in the absence of complete duct transection is safe in children and does not appear to be associated with adverse sequelae. The purpose of this report is to describe the diagnostic techniques, clinical management and survival of 9 children with traumatic injuries of the pancreas treated in our institution over a period of 7 year.
Assuntos
Pâncreas/lesões , Ferimentos não Penetrantes , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapiaRESUMO
The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective and leads to both patients and parents' satisfaction and significant short term improvement. The authors describe their experience with the study and treatment of children with severe chronic constipation in a newly-created Pediatric Bowel Management Clinic (BMC). Further studies will examine the long-term impact of the clinic.
Assuntos
Constipação Intestinal/terapia , Adolescente , Algoritmos , Criança , Doença Crônica , Feminino , Hospitais Especializados , Humanos , Masculino , Índice de Gravidade de DoençaRESUMO
Over a 14-year period, a total of 40 patients underwent surgical revision after an unsuccessful orchiopexy attempt. Overall, 34 reorchiopexies (1 bilateral) and 7 orchiectomies were performed. All reorchiopexies were carried out using extensive mobilization of the testis and spermatic cord. This approach was sufficient for scrotal placement of the testis in 23 instances; however, it was necessary to transpose the spermatic vessels medially in the remaining 11 (incision of the transversalis fascia in 5, incision of the transversalis fascia and division of the inferior epigastric vessels in 6). Only 1 prepuberal boy developed testicular atrophy (2%). Functional long-term assessment was done in 20 postpuberal patients using testicular ultrasound and sperm analysis. The reoperated cryptorchid testes were significantly smaller than the controls (P < 0.005), but decreased fertility was only noted in 3 patients (18.7%). We conclude that testicular volume in adulthood is not directly related to fertility, so that accurate reorchiopexy seems to be the best way to preserve fertility in this special group of cryptorchid patients.
Assuntos
Criptorquidismo/cirurgia , Testículo/cirurgia , Criança , Humanos , Masculino , Orquiectomia , Reoperação , Espermatozoides , Resultado do TratamentoRESUMO
The purpose of this review of patients was to look at the current role of transureteroureterostomy in children. In addition, this study should give an indication of the long-term safety of transureteroureterostomy in children with neurogenic bladder. From 1972 on, 70 subjects between the ages of 2 and 13 underwent transureteroureterostomy. In 68 patients (97 %), transureteroureterostomy was used as a salvage renal procedure after unsuccessful ureteroneocytostomy attempts at other institutions. In 2 patients (3 %), transureteroureterostomy was used as a diversion procedure. The postoperative course was uneventful except for 1 case of early anastomotic occlusion successfully treated by application of a double-J stent. No patient required surgical revision of the ureteral anastomosis. However, 4 patients with neurogenic bladder from myelomeningocele developed sequelae. Of these, 1 presented with stenosis at the end of the recipient ureter, 2 had occurrence of vesicoureteral reflux in nonreimplanted recipient ureter, 1 developed calculi in the donor pelvis. This study supports the view that transureteroureterostomy is highly useful for the management of children with a wide spectrum of urological anomalies. However, long-term monitoring of patients with neurogenic bladder who have undergone this procedure is essential to achieve a long-term good outcome.
Assuntos
Ureterostomia/métodos , Bexiga Urinaria Neurogênica/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVE: To assess the role of infection in the management of children with urachal cysts. METHODS: A retrospective study on 10 children with urachal cysts operated on over an 11-year period (from 1987 to 1998) was performed. Uncomplicated urachal cysts were found in 2 children who underwent primary cyst removal. The remaining 8 were admitted with severe sepsis due to the presence of a urachal abscess; they were managed by a staged approach including percutaneous drainage and delayed cyst removal. The diagnosis of urachal cyst was readily made by ultrasound in all the 10 patients (100%). In 1 patient with urachal abscess, computed tomography provided additional information. RESULTS: The postoperative course was uneventful in 9 of 10 children (90%). A 5-year-old female patient developed peritonitis following urachal abscess rupture into the peritoneal cavity, which resulted in additional surgery and prolonged hospitalization. CONCLUSIONS: (1) Ultrasound is an excellent diagnostic tool for patients with urachal cysts. (2) A renal screening ultrasound must be included in the preoperative work-up. (3) A thorough urological assessment is indicated in patients with abnormal renal ultrasound of recurrent urinary infections. (4) At present, a staged surgical procedure still remains the most effective surgical option in children with urachal cyst.
Assuntos
Abscesso/complicações , Cisto do Úraco/complicações , Abscesso/epidemiologia , Abscesso/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Cisto do Úraco/epidemiologia , Cisto do Úraco/cirurgiaRESUMO
The authors describe a 3-year-old boy with pneumatosis cystoides intestinalis (PCI) and associated duodenal stenosis who came to them with abdominal pain, significant abdominal distension, large gastric residue, and pneumoperitoneum. PCI is a rare condition in children characterized by the presence of multiple gas-filled cysts within the wall of some part of gastrointestinal tract that may break and cause pneumoperitoneum without an intestinal perforation. Even if in most cases the standard treatment is surgical, to keep in mind this rare condition could be useful to adopt a most rational treatment approach and avoid unnecessary operation in case of "benign" pneumoperitoneum.
Assuntos
Pneumatose Cistoide Intestinal/complicações , Pneumoperitônio/etiologia , Pré-Escolar , Humanos , MasculinoRESUMO
Fecal incontinence or soiling always endangers the personality development of a children. For very severe cases, the patient will be limited on his educational and professional training as well as on his sexal life. The outlook of severe cases, the chances of completing school, the choice of professional training and of sexual life in the future will be limited. A corrective procedure for anorectal incontinence depends on the exact investigation of all factors contributing to continence. The aim of this paper is to analyze the diagnostic aspects concerning continence in order to choose for each patient the most appropriate procedure for the treatment of all disturbance of stool control. A long term review of 312 patient with MAR, Myelomeningocele and severe stipsis with soiling was undertaken to determine the level of continence achieved. The choice between conservative measures and surgical procedures depends on clinical and manometric findings.
Assuntos
Incontinência Fecal/classificação , Adolescente , Adulto , Fatores Etários , Canal Anal/lesões , Incontinência Fecal/diagnóstico , Incontinência Fecal/cirurgia , Feminino , Humanos , Masculino , Reto/lesões , Traumatismos da Medula Espinal/complicações , Disrafismo Espinal/complicaçõesRESUMO
OBJECTIVE: To evaluate the efficacy of the vessel transposition technique in ureterovascular hydronephrosis in children. METHODS: Over a 25-year period, we treated 111 patients with 112 instances of ureterovascular hydronephrosis. In order to determine the obstructive effect of the vessels, we performed an intraoperative diuretic test. Using this approach, 61 patients judged to have only vascular pyeloureteral junction obstruction underwent vessel transposition. However, 50 patients in whom the intraoperative diuretic test proved doubtful needed pyeloplasty. RESULTS: Surgical success was achieved in 98% of the patients. Only 1 child treated by vessel transposition had an unsatisfactory outcome which necessitated a subsequent pyeloplasty for persistent hydronephrosis. This was due to a previously unrecognized intrinsic pyeloureteral junction obstruction. CONCLUSION: Based on our clinical experience, the intraoperative diuretic test has proven to be a safe and effective diagnostic tool in children with ureterovascular hydronephrosis. Its use may contribute to treating some cases of ureterovascular hydronephrosis without resorting to pyeloplasty.
Assuntos
Hidronefrose/cirurgia , Pelve Renal/cirurgia , Artéria Renal/anormalidades , Ureter/irrigação sanguínea , Obstrução Ureteral/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Hidronefrose/diagnóstico , Hidronefrose/etiologia , Lactente , Masculino , Prognóstico , Artéria Renal/diagnóstico por imagem , Resultado do Tratamento , Ultrassonografia , Ureter/diagnóstico por imagem , Obstrução Ureteral/diagnóstico , Obstrução Ureteral/etiologia , Urografia , Procedimentos Cirúrgicos Urológicos/métodosRESUMO
Central venous catheterization is a reliable technique in neonatal surgery. Nevertheless, the rate of mechanical catheter-related complications remains high. We report a neonate with gastroschisis in which the successful placement of a central venous catheter was followed later by a cardiac tamponade with a fatal outcome. This complication occurred without perforation of the cardiac wall. A similar finding has been reported in only one other pediatric patient. Vigilant observation is required in any neonate with a central venous line in place to prevent the occurrence of this life-threatening event.