[Use of laparoscopy in neonatal pathology: our experience]. / Uso de la laparoscopia en la patología duodenal: nuestra experiencia.

The neonatal duodenal pathology has been diagnosed and treated with open surgery for many years. The use of minimally invasive techniques is widely use today on pediatric surgery, but its use on neonatal pathology poses a challenge. We have conducted a study of the 8 neonatal patients with duodenal obstruction that were operated with a laparoscopy in our hospital between 2001 and 2007. The analyzed parameters were the gender, prenatal diagnostic, type of duodenal malformation, weight at birth, hospitalization stay, start of feeding, complications and follow-up. In our sample (6 girls and 2 boys) the 62.5% of the cases was diagnosed after a prenatal ultrasound scan. The duodenal malformations discovered were 5 atresias, 2 webs and 1 anular pancreas. In all the cases, the feeding started by means of a trans-anastomotic probe 48 hours postoperatives. There were 3 complications: one re-surgery and 2 stenosis of anastomosis. The average hospitalization stay was of 27 days with a mean follow-up of 3 years. We think that laparoscopy is a good method for the treatment of the neonatal duodenal pathology, although the scarce volume of our sample does not allow us to generalize the technique.

Resultados iniciales del tatamiento de la hernia inguinal por vía laparoscópica / Laparoscpic inguinal herniorrhaphy in children. First results

Introducción: La herniorrafía inguinal tiene una nueva alternativa, la vía laparoscópica. En este trabajo analizamos los resultados iniciales obtenidos mediante esta técnica en el tratamiento de la hernia inguinal, en nuestro hospital, evaluando las indicaciones y su eficacia. Material y métodos: Estudiamos 150 pacientes con diagnóstico de herniainguinal o crural. La técnica la efectuamos con tres trócares: unoumbilical de 5mm para la óptica y dos de 3 mm situados en ambos flancos. La reparación se realizó con bolsa de tabaco, sutura continua o puntos sueltos, utilizando siempre material irreabsorbible. Resultados: Las indicaciones fueron: hernia inguinal recidivada en el12%, hernia inguinal bilateral en el 28%, asociación de hernia inguinal unilateral y hernia umbilical en el 39%, hernia crural en el 4% y en el16% se reparó la hernia al ser encontrada incidentalmente. En la mayoría de los casos (137) el cierre del anillo inguinal se realizó mediante una sutura en bolsa de tabaco sin sección del peritoneo, en 11 se hizo una sutura continua y en 12 casos se cerró mediante puntos sueltos. No hubo reconversión en ningún caso. Se produjo hematoma por punción de los vasos espermáticos en 6 casos (1,4%). Inicialmente el ingreso fue de 1 a 2 días; actualmente lo hacemos de forma ambulatoria. Hemos tenido 2 casos de recidiva (1%) que fueron tratados por vía laparoscópica. Conclusiones: Aunque el número de pacientes tratados impide sacar unas conclusiones definitivas pensamos que el tratamiento laparoscópico de las hernias inguinocrurales, puede ofrecer ciertas ventajas sobre la vía abierta en casos seleccionados (AU)

Introduction: The inguinal hernia repair in the child has anew alternative, the laparoscopic repair. We study our initial results obtained with this technique. We evaluate the indications and the efficiency. Material and methods: 150 patients have been operated with an initial diagnosis of hernia inguinal or crural. Usually this technique is realized with three ports: we put the umbilical one (5mm) for the scope and two ports (3mm) placed in flanks. The repair was realized in purse string fashion or interrupted or no interrupted suture with non-absorbable suture (polipropylen) 3-4/0.Results: Indications of the herniorraphy were: (12 %) recurrent hernia, bilateral hernia (28 %), association inguinal hernia inguinal and umbilical(39 %), crural hernia (4 %) and in 16 % incidental hernia. Most of them (137) was treated in purse string fashion, (11) non interrupted suture and 12 interrupted suture. No conversion to open was require in any case. Haematoma for puncture of the spermatic vessels was seen in6 cases (1'4 %). Today we do this surgery in ambulatory way. We have had 2 recurrent hernias (1 %) that were treated again laparoscopicaly Conclusions: We can’t extract conclusion from this study because of the number of patients but we think that the laparoscopic treatment of inguinal hernias can offer advantages in selected cases (AU)

[Laparoscopic inguinal herniorrhaphy in children. First results]. / Resultados iniciales del tratamiento de la hernia inguinal por vía laparoscópica.

INTRODUCTION: The inguinal hernia repair in the child has a new alternative, the laparoscopic repair. We study our initial results obtained with this technique. We evaluate the indications and the efficiency. MATERIAL AND METHODS: 150 patients have been operated with an initial diagnosis of hernia inguinal or crural. Usually this technique is realized with three ports: we put the umbilical one (5mm) for the scope and two ports (3 mm) placed in flanks. The repair was realized in purse string fashion or interrupted or noninterrupted suture with non-absorbable suture (polipropylen) 3-4/0. RESULTS: Indications of the herniorraphy were: (12%) recurrent hernia, bilateral hernia (28%), association inguinal hernia inguinal and umbilical (39%), crural hernia (4%) and in 16% incidental hernia. Most of them (137) was treated in purse string fashion, (11) non interrupted suture and 12 interrupted suture. No conversion to open was require in any case. Haematoma for puncture of the spermatic vessels was seen in 6 cases (1,4%). Today we do this surgery in ambulatory way. We have had 2 recurrent hernias (1%) that were treated again laparoscopicaly. CONCLUSIONS: We can't extract conclusion from this study because of the number of patients but we think that the laparoscopic treatment of inguinal hernias can offer advantages in selected cases.

[Alternative treatment of gastroesophageal reflux: endoluminal gastric plication]. / Tratamiento alternativo del reflujo gastroesofágico: plicatura gástrica endoluminal.

Gastroesophageal reflux is a common chronic disorder that is presented in infants under different clinical pictures. Adolescents with heartburn, dependent on acid supression therapy is a group of patients refered with increased frequency to pediatric surgeons. To date, the accepted methods of management are long term medication or surgery. Recently, different endoscopic techniques have been described to treat gastroesophageal reflux. Endoscopic antireflux suturing is one of this developed methods. In this paper, we present the preliminary results in the treatment of pediatric patients with an endoscopic suturing device. The procedure was accomplished in six patients and the results were analized 6 months after the placement of the sutures. We have obtained an improvement in clinical symptoms reduction, in terms of frequency as well as in intensity. Acid supression therapy was also reduced significantly. There were no complications during the endoscopic procedure, neither in the postoperative course. Patients, were agree with the technique and the clinical results obtained. Endoscopic suturing is a safe procedure that can be an alternative in the treatment of selected patients with gastroesophageal reflux, in the pediatric age group.

[Thoracoscopic repair of esophageal atresia]. / Tratamiento toracoscópico de la atresia de esófago.

We present the first three cases of esophageal atresia with tracheoesophageal fistula treated with a thoracoscopic approach in our Service. The technique was accomplished through three trocar inserted in the right hemithorax. Carbon dioxide insufflation was required for lung retraction Primary correction was carried out in all the cases without major perioperative complications. The mean surgical time was 240 minutes. One patient had an anastomotic leak, resulting in a complicated postoperative course. The leak healed on conservative treatment. The others two patients were fed at the seventh postoperative day. Mean hospital stay in these cases was 12 days. Although thoracoscopic repair of esophageal atresia with fistula is a currently feasible technique that offers different advantages on the conventional open technique, a greater number of cases is needed in order to advance in the learning curve and determine the exact place that this technique can have in the future treatment of esophageal atresia.

[Jejunal diaphragm. Laparoscopic treatment in newborns]. / Atresia yeyunal membranosa. Tratamiento laparoscopico en periodo neonatal.

Intestinal obstructions in newborns secondary to atresias or membranes have been treated until the current moment through laparotomy and resection with anastomosis. Recently, it has been reported the use of minimally invasive techniques to correct this congenital anomaly. We present a case of jejunal diaphragm treated in our Service. Diagnosis and treatment by mean of endoscopic techniques was achieved in the fourth day of life. Operative time was 180 minutes. Postoperative course was uneventful. Results in terms of function and cosmetic were excellent. Laparoscopic management in selected cases of intestinal atresia has proven to be safe and effective and represents an alternative to neonatal open surgery.

Tratamiento alternativo del reflujo gastroesofágico: Plicatura gástrica endoluminal / Pyeloplasty follow-up. How and how long?

El reflujo gastroesofágico (RGE) es una patología crónica que en la infancia se presenta bajo diferentes cuadros clínicos. Un grupo de pacientes cada vez más frecuentemente remitido a las consultas de cirugía pediátrica es el de adolescentes con pirosis, que dependen del tratamiento con inhibidores de la secreción ácida. El tratamiento habitual en estos casos es el mantenimiento de la medicación de forma indefinida o la cirugía. Recientemente se han descrito diferentes tratamientos endoscópicos para el control del RGE, siendo uno de ellos la realización de suturas intraesofágicas. En este trabajo analizamos los resultados preliminares del tratamiento endoscópico de pacientes pediátricos mediante sutura endoluminal. Se presentan seis pacientes a los cuales se les realizó este procedimiento y se analizan los resultados obtenidos a los 6 meses de su colocación. Hemos obtenido una mejora en la reducción de síntomas clínicos, tanto en frecuencia como en intensidad, así como en la necesidad de medicación antisecretora. No hubo complicaciones durante el desarrollo de la técnica endoscópica, ni en el postoperatorio. La aceptación de la técnica y la valoración del tratamiento por parte de los pacientes ha sido muy buena. La sutura endoscópica es un sistema seguro que se puede convertir en una alternativa en el tratamiento, para pacientes seleccionados, del RGE en la edad pediátrica (AU)

Estenosis congénita de colon / Congenital colonic stenosis

Las atresias y estenosis cólicas congénitas son las atresias intestinales menos frecuentes, representando del 5 al 15% de todas ellas. Se presenta el caso de un varón que debuta a los 2 meses de edad con un cuadro de vómitos, estreñimiento, decaimiento y distensión abdominal. Mediante la realización de enema opaco con gastrografín y colonoscopia, y tras haber descartado otras enfermedades, se estableció el diagnóstico de estenosis cólica. Se decidió instaurar tratamiento quirúrgico y se realizó laparoscopia bajo anestesia general en la que se visualizó una zona estenótica en el colon sigmoide y dilatación proximal. A través de una mínima incisión se practicó resección videoasistida de la estenosis con anastomosis colocólica terminoterminal. El postoperatorio transcurrió con normalidad. En controles posteriores con enema opaco el colon presentaba un calibre normal. A los 18 meses de vida el paciente se encontraba asintomático, realizando deposiciones con normalidad. La utilización de la laparoscopia ha permitido la amplia y detallada visualización de la cavidad abdominal, localizando fácilmente el lugar de la lesión y descartando otros procesos. Además de la rápida recuperación, el resultado funcional y estético en este caso fue excelente (AU)

[Congenital colonic stenosis]. / Estenosis congénita de colon.

The colon is the least common site of congenital intestinal stenosis and atresia and accounts for 5-15 % of all of these abnormalities. We present the case of a 2-month-old boy who presented vomiting, constipation, weakness, and abdominal distension. Contrast enema and colonoscopy revealed an abrupt change in caliber in the sigmoid colon and, after ruling out other disorders, a diagnosis of colonic stenosis was made. Laparoscopy under total anesthesia was performed and a stenotic area in the sigmoid colon and proximal dilatation were identified. A small incision was made and the stenotic segment was removed. Video-assisted resection and end-to-end anastomosis were performed and the child made and uneventful postoperative recovery. Contrast enema after surgery showed good anastomosis and normal bowel diameter. At the age of 18 months the patient is asymptomatic and his stools are normal. With laparoscopy, visualization of the abdominal cavity was magnified and detailed, the affected intestinal segment was easily identified and other diseases were ruled out. Recovery was rapid and the functional and esthetic results were excellent.

Análisis del fracaso de la cirugía antirreflujo / Study of fundoplication failure

La reaparición de síntomas de reflujo gastroesofágico (RGE) después de realizarse una funduplicatura es un grave problema, ya que la sintomatología es refractaria al tratamiento médico y es necesario efectuar una segunda operación antirreflujo en condiciones técnicas más difíciles. Se han identificado diferentes factores que contribuyen al fallo de este tipo de intervenciones en el niño. Presentamos ocho pacientes en los cuales realizarnos una segunda técnica antirreflujo después del fallo de la técnica inicial, sobre una serie total de 96 pacientes intervenidos por reflujo gastroesofágico. En cuatro casos la primera intervención fue realizada en nuestro servicio. Seis pacientes tenían lesiones o déficit neurológico, seis padecían patología respiratoria crónica y dos casos presentaban atresia de esófago. Los síntomas principales fueron recurrencia del vómito (n = 8) y aspiración (n = 4). La reaparición del reflujo se confirmó mediante esofagograma y endoscopia. Los hallazgos operatorios fueron: rotura del manguito de la funduplicatura en dos casos, rotura del manguito asociado a hernia hiatal en cinco casos, rotura del manguito asociado a hernia paraesofágica en dos casos y hernia paraesofágica con manguito normal en uno. Se efectuó una segunda funduplicatura de Nissen en cinco pacientes, y en tres niños en los que se consideró que tenían un 'esófago corto', realizamos una gastroplastia de Collis-Nissen. En seis casos la evolución clínica ha sido satisfactoria; un paciente presenta una disfagia severa y otro recurrencia de los vómitos. En nuestra experiencia, los pacientes con enfermedad por reflujo gastroesofágico recurrente, precisan una técnica antirreflujo adaptada de forma específica a sus alteraciones anatómicas o funcionales (AU)

[Analysis of anti-reflux surgery failure]. / Análisis del fracaso de la cirugía antirreflujo.

Recurrent gastroesophageal reflux following fundoplication is a challenging problem, because it is usually refractory to medical treatment and a second, technically difficult, antireflux operation is required. Different factors that may contribute to surgery failure have been identified in children. We present 8 cases who underwent redofundoplication after failed procedures, from a total number of 96 patients operated on due to gastroesophageal reflux. Four patient's had their initial fundoplication performed at our institution. Six patients were neurologically impaired, six had chronic pulmonary disease, and two had esophageal atresia. The main presenting symptoms were recurrent vomiting (n = 8) and aspiration (n = 4). Gastroesophageal reflux was confirmed by barium swallow and endoscopy. Operative findings showed wrap breakdown in two cases, warp breakdown associated with hiatal hernia in five, wrap breakdown associated with paraesophageal hernia in two cases, and paraesophageal hernia with normal wrap in one. A second Nissen procedure were performed in five cases, whereas a Collis-Nissen gastroplasty was realized in three with a short esophagus. Six patients had a successful outcome remaining symptom free, one has severe disphagia, and one has recurrent vomiting. In our experience, patients with recurrent gastroesophageal reflux disease should undergo an antireflux procedure tailored to specific anatomic or functional abnormalities.

[Surgical treatment of myasthenia gravis in children using transsternal thymectomy]. / Tratamiento quirúrgico de la miastenia gravis en niños mediante timectomía transesternal.

Myasthenia gravis is an inmunological disease infrecuent during childhood. In recent years, thymectomy has gained increasing acceptance as the most effective treatment for acheiving sustained improvement in patients affected of myasthenia gravis. We report our experience in five children treated by trassternal radical thymectomy in the last five years. This patients were clinically staged following Osserman's classification as stage IIB (three cases) and stage III (two cases). All of them are in complete remission after a mean postoperative period of thirty three months. We add a review of the literature comparing the differents surgical approaches for thymectomy and its results in children.

[Long-term course of esophageal stenosis treated with pneumatic dilatation. A comparative study versus other methods]. / Evolución a largo plazo de las estenosis de esofágo tratadas con dilataciones neumáticas. Estudio comparativo con otros métodos.

Dilatation of benign esophageal strictures by means of a balloon catheter is a well established procedure in children. In this report a comparison of bouginage and balloon dilatation is made in eight patients treated by both procedures. The lesions treated included two strictures secondary to surgical anastomosis, one restrictive Nissen fundoplicature and five esophageal stenosis following caustic ingestion. These eight patients had a total of 44 bouginage procedures with a mean relapse free period of 80 days. There were two esophageal perforations. The clinical course was unsatisfactory in five cases. Only one patient had good results. In contrast, to date, the 15 balloon dilatations have resulted in a mean relapse free time of 174 days. There were no complications that required treatment. The clinical follow up shows four asymptomatics patients and the other four presenting difficulties to swallow with spontaneous resolution. We have the best results in younger patients with esophageal stenosis secondary to esophageal atresia repair. Balloon dilatation of esophageal stenosis in children is effective and safe, and should be considered before other methods of treatment are used.