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Abdominal surgical emergencies are relatively common in neonates. Some of them are related to congenital diseases such as intestinal atresia and intestinal malrotation, whereas some are entirely postnatal conditions such as necrotizing enterocolitis and gastric perforation. While there is a wide range of clinical severity for these conditions, outcomes are most favorable with prompt identification and expeditious treatment. In this review, we describe the most common neonatal abdominal surgical emergencies, highlight the signs that can help with early detection, and explain the approach to diagnosis and management.

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With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

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AIM: The aim of this study was to evaluate the outcome of all patients who underwent an extrathoracic esophageal elongation (EEE) (Kimura's technique) and determine its role, among other surgical options, for the treatment of patients with complex esophageal atresia (EA) who have a previously created esophagostomy. METHODS: Between March 1997 and September 2008, we performed 20 EEEs. Twelve patients were males and 8 were females. The diagnoses were type C EA (n = 12), type A EA (n = 5), type B EA (n = 2), and type D EA (n = 1). Mean age at the initiation of the EEE was 10 months (range, 3-25 months). RESULTS: At the time of this report, 15 of the 20 patients have finished the treatment, 4 patients are still in the process of elongation, and one patient (premature, with a birth weight of 685 g) died before the final esophageal reconstruction. Of the 15 patients who finished the treatment, 12 (80%) completed it satisfactorily and 3 (20%) had to be prematurely interrupted. (In 2 patients, despite multiple attempts, the upper pouch could not be adequately elongated, and in one patient, an early perforation of the upper pouch precluded further elongations.) Of the 12 patients who completed the treatment satisfactorily, 10 (83%) are asymptomatic and exclusively on oral alimentation, whereas 2 (17%) have a pseudodiverticulum and esophageal dysmotility (requiring supplemental alimentation through a gastrostomy). Five of the 12 patients have gastroesophageal reflux (2 required a Nissen fundoplication and 3 are being treated medically). CONCLUSIONS: We believe that the EEE is a useful surgical option for a selected group of patients with complex long-gap EA who required a primary esophagostomy and also for patients with any type of EA who developed severe complications after a primary repair and required a secondary esophagostomy. With this technique, we avoided an esophageal replacement in 80% of cases, and given that the EEE does not invalidate a later esophageal replacement, we believe that the EEE is a feasible initial option for these patients.

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OBJECTIVE: The aim of this report was to present our experience with a modified surgical technique designed for the treatment of choledochal cysts (CC) in children. MATERIALS AND METHODS: Between June 2004 and February 2005, we operated on 6 patients with a diagnosis of type I CC by means of a "leak-free" technique that consists of a transient complete sealing of the hepatic duct for the duration of the dissection, and a single- or double laparoscopic running suture to build the end-to-side hepatico-jejuno anastomosis. There were 4 females and 2 males, whose age ranged between 45 days and 7 years (median, 45 months). All cases were performed with three trocars plus the scope, and two or three percutaneous stay-stitches to retract the liver. The end-to-side hepatico-jejuno anastomoses were done with 5.0 or 6.0 PDS. We left no drains. RESULTS: The mean operative time was 335 minutes, and mean postoperative time to oral feeding was 44 hours. The mean hospital stay was 6 days (range, 5-10). No postoperative biliary leak was observed. A cosmetic result was excellent in all patients. In the follow-up (mean, 12 months), all patients were asymptomatic, had no intrahepatic biliary tree dilation, and had normal liver function tests. CONCLUSIONS: Based on the results of our series, we think that the laparoscopic approach is suitable for these patients, but some surgical details should be followed to lower the complication rate. First, a temporary closure of the hepatic duct to prevent bile spillage during the dissection is important for keeping the area clean and thus reducing the operative time. Second, the use of a running suture for the hepatico-jejunostomy, even though it may be technically challenging, should always be attempted to avoid postoperative bile leaks in these high-flow anastomoses.

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Assuntos

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Congenital esophageal stenosis (CES) is an infrequent entity; however, many cases have been reported during the last years. Its incidence falls between 1 per 25,000 and 1 per 50,000 live births and is associated with other congenital malformations in 17% to 33% of cases (mainly esophageal atresia). Congenital esophageal stenosis is defined as an intrinsic alteration of the esophageal wall given by the presence of ectopic tracheobronchial tissue, membranous diaphragm, muscular hypertrophy, or diffuse fibrosis of the submucosa, among other causes. The therapeutic options include endoscopic dilation and resection plus anastomosis (by either laparotomy or thoracotomy, depending on the level of the stenosis). We present the case of a 1-month-old baby boy with a CES located in the distal esophagus that is associated with anophthalmia and micropenis. We treated the lesion by means of a thoracoscopic resection of the affected segment and an esophageal end-to-end anastomosis. The patient's long-term outcome was uneventful. As far as we know, this is the first report on thoracoscopic resolution of a CES.

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Minimally invasive surgery (MIS) has overcome many technical limitations and has evolved into a safe alternative for the treatment of many complex pediatric surgical procedures. The introduction of this approach for the correction of congenital biliary tract anomalies had to wait until instrumentation and surgeons' skills improved enough. This happened not so long ago: less than 10 years have elapsed since the first reported case of a minimally invasive operation for choledochal cyst and less than 3 years since the first reported case of a laparoscopic Kasai. This article summarizes the experience gained by the authors in laparoscopic treatment of 41 patients with biliary atresia and 15 patients with choledochal cyst with similar surgical techniques, which are described in detail. Based on the encouraging results, the authors believe that MIS will soon become the gold standard for the correction of congenital biliary tract anomalies.

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During the last years, several thoracic and abdominal enteric duplications were resected in our institution by means of minimally invasive approaches [Rev Cir Infantil 1999;9(2):113-115]. Our last patient, however, had a giant thoraco-abdominal duodenal duplication, extending from the upper thoracic cavity to the pelvis, in a dumbbell fashion. Forty days after birth, a combined "thoraco-laparoscopy" was performed, achieving a complete resection of the cyst. The diaphragmatic defect was repaired as well. Recovery was uneventful. Based on this successful experience, we think that the thoraco-laparoscopic approach is suitable and reproducible for patients with these infrequent malformations, and even for patients with other kinds of thoraco-abdominal lesions. The purpose of this report was to describe the minimally invasive strategy used to approach the thorax and the abdomen in a single-stage procedure.

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Wandering spleen is a very uncommon condition. Because of the risk of pedicle torsion and splenic ischemia, severe consequences may occur if not diagnosed and treated in time. Unfortunately, splenectomy is sometimes necessary (ie, when splenic infarction occurs). Once the diagnosis of wandering spleen is made, splenopexy is the treatment of choice. There are numerous techniques designed for splenopexy, either by open surgery or by minimally invasive approaches. We describe here a laparoscopic procedure that allows an excellent fixation of the spleen using the patient's own tissues. After a 2-year follow-up, the organ remains in place with good perfusion.

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