Anti-reflux surgery for patients with esophageal atresia.

Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long-term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one-fifth have Barrett's metaplasia. Close to 100%, GER of pure and long-gap cases require fundoplication. In the long run, these patients have 50-fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long-gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.

Gastroesophageal reflux after repair of esophageal atresia.

BACKGROUND AND AIMS: Gastroesophageal reflux (GER) is extremely frequent in patients with esophageal atresia and tracheoesophageal fistula (EA/TEF). It is often refractory to antireflux medication and requires antireflux surgery. The reasons for this close association, the dangers of persistent GER, and the indications, technical aspects, and pitfalls of antireflux operations in these patients are examined in the present study. METHODS: The literature and summary of a large institutional experience of the authors were reviewed. RESULTS: The esophagus is permanently defective in EA/TEF patients even when successful repair, sometimes under tension, has been achieved. Extrinsic and intrinsic innervations are abnormal and consequently, motor function and sphincters are defective. The result is that close to one half of these patients overall suffer chronic GER that leads often to Barrett esophagus. Fundoplication becomes necessary in more than 40% of them, particularly in cases of with refractory anastomotic stenoses and in those with pure and long-gap EA/TEF. In the long run, the risks of esophageal carcinoma are 50-fold higher in EA/TEF survivors than in the population at random. On the contrary, fundoplication is anatomically difficult to perform and it fails in one-fifth of these children due to the persistence of the conditions that facilitate GER in them. CONCLUSIONS: GER is extremely frequent in patients treated for EA/TEF because of serious structural and functional deficiencies. It is refractory to medical treatment and often requires antireflux surgery. However, the high rates of wrap failure invite close follow-up in all cases and reoperation or other measures whenever necessary.

Current controversies in the surgical treatment of esophageal atresia.

BACKGROUND AND AIMS: Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a rare condition that can be nowadays succesfully treated. The current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results. METHODS: The current strategies for the difficult or impossible anastomoses in pure and long-gap EA, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (GER) are reviewed. RESULTS: Methods of esophageal elongation and multi-staged repair of pure and long-gap EA allow anastomosis but with functional results that are often poor. Esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. Thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. GER is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates. CONCLUSIONS: EA with or without TEF can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.

Escisión laparoscópica de quiste mesotelial hepático / Laparoscopic excision of a hepatic mesothelial cyst

Los quistes mesoteliales son lesiones congénitas extremadamente raras que tienen origen en restos celómicos. Los autores describen el caso de un niño de tres años de edad. Presenta como hallazgo casual imagen quística hepática en ecografía abdominal, en el contexto de estudio de dolor abdominal. El examen objetivo y el estudio analítico no demostraron ninguna alteración. La RMN confirmó la presencia de lesión quística, sugiriendo como hipótesis diagnóstica tratarse de un cistadenoma quístico. El enfermo fue sometido a quistectomía por laparoscopia, con alta al 2º día. El estudio de anatomía patológica concluye que se trata de un quiste mesotelial hepático. Los quistes mesoteliales hepáticos son lesiones muy raras, de difícil diagnóstico preoperatorio. Su escisión laparoscópica es un procedimiento exequible y seguro (AU)

Over the past few years there has been an increase in application of minimally invasive techniques in pediatric surgery, especially in the approach of liver lesions. The mesothelial cysts are extremely rare congenital lesions that arise from celomic remnants. The authors present the clinical case of a three year old child, referred to our institution after an incidental finding of a liver cystic lesion in abdominal ultrasound. The physical examination and blood study were irrelevant. The MRI confirmed the presence of the cystic lesion and pointed, as a possible etiology, a cystic cyst adenoma of the liver. The child was submitted to laparoscopic cyst resection. There peri and postoperative periods were uneventful. He was discharged 48h after surgery. The anatomo-pathological and immunohistochemical studies concluded it was a mesotelial cyst of the liver. The mesothelial cysts of the liver are very rare lesions, with difficult preoperative diagnosis. The laparoscopic excision is a feasible and safe (AU)

Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience.

PURPOSE: To evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children. MATERIALS AND METHODS: Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO(2) pneumovesicum. Ports were inserted suprapubically - 5mm for the camera and two 3-5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography+/-voiding cystourethrogram. RESULTS: Ninety percent had VUR grade > or =3. A total of 113 ureters were reimplanted. The mean operative time was 82min for unilateral and 130min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%). CONCLUSIONS: Laparoscopic ureteric reimplantation with CO(2) pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.

[Laparoscopic excision of a hepatic mesothelial cyst]. / Escisión laparoscópica de quiste mesotelial hepático.

Over the past few years there has been an increase in application of minimally invasive techniques in pediatric surgery, especially in the approach of liver lesions. The mesothelial cysts are extremely rare congenital lesions that arise from celomic remnants. The authors present the clinical case of a three year old child, referred to our institution after an incidental finding of a liver cystic lesion in abdominal ultrasound. The physical examination and blood study were irrelevant. The MRI confirmed the presence of the cystic lesion and pointed, as a possible etiology, a cystic cyst adenoma of the liver. The child was submitted to laparoscopic cyst resection. There peri and postoperative periods were uneventful. He was discharged 48h after surgery. The anatomo-pathological and immunohistochemical studies concluded it was a mesotelial cyst of the liver. The mesothelial cysts of the liver are very rare lesions, with difficult preoperative diagnosis. The laparoscopic excision is a feasible and safe.