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.

Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results.

INTRODUCTION: Bladder exstrophy (BE) is a rare, complex malformation. There are three major approaches to closure. Despite this choice, abdominal wall closure in such patients is usually a challenging procedure specially in large defects and redo cases. OBJECTIVE: Our aim is to present our ten first cases' results, using Anterior Component Separation (ACS) to abdominal wall closure in BE patients. STUDY DESIGN: Ten male patients with BE (median age 7 months, range from 3 to 24 months) were operated from March 2020 to March 2021 by a multi-institutional Brazilian group using the Kelly technique. In addition to BE correction, anterior component separation was performed for abdominal closure. RESULTS: Postoperative suprapubic fistulae occurred in two of ten patients, but both closed spontaneously. No evisceration, abdominal wall dehiscence, or herniation was observed at a mean follow-up time of 14 months (range from 10 to 22 months). A 3 cm extent of advancement is achievable upon traction in each side (Fig. 3). CONCLUSION: We proposed the use of anterior component separation as an alternative for abdominal closure after BE correction using the Kelly procedure. This new technique avoids mesh usage, loosens the abdominal wall tension, and reduces complications. Even However, further studies are required.

Does single-site robotic surgery makes sense for gallbladder surgery?

BACKGROUND: Cholecystectomy is one of the most performed surgeries. Several techniques were created, generating less pain, better aesthetic results and faster return to activities. Robotic surgery through a single portal combined the advantages of single-incision surgery with the principles of conventional laparoscopy, making it a safe and feasible procedure. However, due to the high costs, this technology is hardly available in practice, especially in the public health system. The objective is to evaluate the safety of robotic cholecystectomy using the da Vinci Single-Site © Surgical Platform (DVSSP) in a tertiary public hospital, and to assess alternatives that can reduce the costs, influencing the final real value of the procedure. METHODS: Prospective and descriptive study evaluating robotic cholecystectomies using the DVSSP technology performed at Hospital de Clínicas de Porto Alegre from May 2017 to November 2018. RESULTS: A total of 37 cholecystectomies were performed. The average time of surgery was 82.62 min, and no intraoperative complications were observed. There was a need for conversion to conventional laparoscopy in two surgeries (5.4%). The average cost of the robotic procedure was U$ 1146.23 and the amount passed on to the institution by the Brazilian Unified Health System was on average U$ 212.59 (p < 0.05). Postoperative outcomes were satisfactory, with an incisional hernia index of 8.1%. CONCLUSION: Although robotic surgery in this setting is a safe and feasible alternative, the high cost of the procedure prevents its dissemination on a large scale. New alternatives are needed to reduce the value and to allow greater accessibility.

Laparoscopy as a Facilitator in the Early Diagnosis of a Mullerian Aplasia During Ordinary Surgery.

Laparoscopy was introduced more than 100 years ago. However, in some fields its use still meets resistance. Technology such as laparoscopy may help to identify rare and complex disorders, even in very ordinary procedures, such as inguinal hernia repair. This report highlighted the importance of early diagnosis of a complex condition using commonly available technology. To the best of our knowledge, there has not been a similar reported case in such a young patient during laparoscopic inguinal hernia repair.

Laparoscopic gonad-sparing procedure in Ovotesticular disorder of sex development - Case video technique.

INTRODUCTION: Ovotesticular disorder of sex development (OTD) is a rare condition. There's a lack of literature addressing gonad-sparing surgery for OTD. OBJECTIVE: Report the laparoscopic partial gonadectomy technique - gonad-sparing surgery - in an 11-year-old child, 46, XX karyotype with OTD with atypical genitalia. MATERIAL AND METHODS: After a complete diagnostic evaluation the patient underwent feminizing genitoplasty followed by laparoscopic partial gonadectomy (gonad-sparing surgery). The patient was positioned on supine position and Trendelenburg. One 5 mm port was placed on the umbilicus and two 3 mm ports in both flanks. A gonadal wedge biopsy was performed to achieve histopathological confirmation before resection. The testicular component of the ovotestis is clearly identified based on macroscopic aspects, and resected with laparoscopic scissors and limited use of electrocautery. DISCUSSION: This case was classified as bipolar or terminal ovotestis. At the 5-month follow-up, the patient attained menarche. No adverse outcomes have been recorded. Postoperative third year follow-up hormone evaluation revealed a= female pattern characteristic and ultrasound demonstraed uterine volume increase, as well as bilateral ovarian tissue development with follicles. CONCLUSIONS: Gonad-sparing procedure is feasible and desirable whenever possible, especially in 46, XX patients with female sex of rearing, since it preserves the fertility potential. The risk of malignancy must be monitored.

Impacto do parto vaginal após uma cesárea prévia sobre os resultados perinatais / Impact of vaginal delivery after a previous cesarean section on perinatal outcomes

OBJETIVO: Analisar o impacto do parto vaginal, após uma cesárea prévia, sobre os resultados perinatais. MÉTODOS: Estudo caso-controle, com seleção de casos incidentes e controles consecutivos, no qual foram analisadas variáveis maternas e perinatais. Compararam-se gestantes secundigestas com parto cesáreo prévio (n=375) e que deram à luz via transpélvica (PVPC), com gestantes com os mesmos critérios de inclusão, mas submetidas a operação cesariana (PCPC, n=375). Foram considerados critérios de inclusão: gestantes secundigestas que tenham dado à luz por meio de parto cesariana na gestação anterior; gestação única e de termo; feto em apresentação cefálica, sem malformação congênita; ausência de placenta prévia ou qualquer tipo de sangramento de terceiro trimestre gestacional. RESULTADOS: No estudo, a taxa de PVPC foi de 45,6%, sendo que 20 deles (5,3%) foram ultimados com o fórceps. Observou-se associação significante entre PVPC e idade materna inferior a 19 anos (p<0,01), etnia caucasiana (p<0,05), número médio de consultas de pré-natal (p<0,001), tempo de ruptura prematura das membranas (p<0,01), tempo de trabalho de parto inferior a 12h (p<0,045), índice de Apgar inferior a sete no 5º minuto (p<0,05), tocotraumatismo fetal (p<0,01) e anoxia (p<0,006). No grupo de recém-nascidos por PCPC observou-se maior frequência de taquipneia transitória (p<0,014), disfunções respiratórias (p<0,04) e maior tempo de internação na unidade de tratamento intensivo neonatal (p<0,016). Houve apenas um caso de ruptura uterina no grupo PVPC. O número de neomortos foi idêntico em ambos os grupos. CONCLUSÕES: A via de parto vaginal em secundigestas com cesárea prévia associou-se a aumento significativo da morbidade neonatal. Serão necessários mais estudos para elaborar estratégias que visem melhorias dos resultados perinatais e de auxílio aos profissionais, de forma que estes possam melhor orientar as suas pacientes na escolha da via de parto mais adequada.

PURPOSE: To analyze the impact of vaginal delivery after a previous cesarean section on perinatal outcomes. METHODS: Case-control study with selection of incident cases and consecutive controls. Maternal and perinatal variables were analyzed. We compared secundiparas who had a vaginal delivery after a previous cesarean delivery (VBAC) (n=375) with secundiparas who had a second cesarean section (CS) (n=375). Inclusion criteria were: secundiparas who underwent a cesarean section in the previous pregnancy; singleton and term pregnancy; fetus in vertex presentation, with no congenital malformation; absence of placenta previa or any kind of bleeding in the third quarter of pregnancy. RESULTS: The rate of vaginal delivery was 45.6%, and 20 (5.3%) women had forceps deliveries. We found a significant association between VBAC and mothers younger than 19 years (p<0.01), Caucasian ethnicity (p<0.05), mean number of prenatal care visits (p<0.001), time of premature rupture of membranes (p<0.01), labor duration shorter than 12 hours (p<0.04), Apgar score lower than seven at 5th minute (p<0.05), fetal birth trauma (p<0.01), and anoxia (p<0.006). In the group of newborns delivered by cesarean section, we found a higher frequency of transient tachypnea (p<0.014), respiratory disorders (p<0.048), and longer time of stay in the neonatal intensive care unit (p<0.016). There was only one case of uterine rupture in the VBAC group. The rate of neonatal mortality was similar in both groups. CONCLUSIONS: Vaginal delivery in secundiparas who had previous cesarean sections was associated with a significant increase in neonatal morbidity. Further studies are needed to develop strategies aimed at improving perinatal results and professional guidelines, so that health care professionals will be able to provide their patients with better counseling regarding the choice of the most appropriate route of delivery.

[Impact of vaginal delivery after a previous cesarean section on perinatal outcomes]. / Impacto do parto vaginal após uma cesárea prévia sobre os resultados perinatais.

PURPOSE: To analyze the impact of vaginal delivery after a previous cesarean section on perinatal outcomes. METHODS: Case-control study with selection of incident cases and consecutive controls. Maternal and perinatal variables were analyzed. We compared secundiparas who had a vaginal delivery after a previous cesarean delivery (VBAC) (n=375) with secundiparas who had a second cesarean section (CS) (n=375). Inclusion criteria were: secundiparas who underwent a cesarean section in the previous pregnancy; singleton and term pregnancy; fetus in vertex presentation, with no congenital malformation; absence of placenta previa or any kind of bleeding in the third quarter of pregnancy. RESULTS: The rate of vaginal delivery was 45.6%, and 20 (5.3%) women had forceps deliveries. We found a significant association between VBAC and mothers younger than 19 years (p<0.01), Caucasian ethnicity (p<0.05), mean number of prenatal care visits (p<0.001), time of premature rupture of membranes (p<0.01), labor duration shorter than 12 hours (p<0.04), Apgar score lower than seven at 5th minute (p<0.05), fetal birth trauma (p<0.01), and anoxia (p<0.006). In the group of newborns delivered by cesarean section, we found a higher frequency of transient tachypnea (p<0.014), respiratory disorders (p<0.048), and longer time of stay in the neonatal intensive care unit (p<0.016). There was only one case of uterine rupture in the VBAC group. The rate of neonatal mortality was similar in both groups. CONCLUSIONS: Vaginal delivery in secundiparas who had previous cesarean sections was associated with a significant increase in neonatal morbidity. Further studies are needed to develop strategies aimed at improving perinatal results and professional guidelines, so that health care professionals will be able to provide their patients with better counseling regarding the choice of the most appropriate route of delivery.