Background: Routine prophylactic abdominal drains after laparoscopic appendectomy for perforated appendicitis in children are still controversial. Throughout the history of surgery, potential benefits of the abdominal drains have been described. However, in recent studies, no benefits were observed and serious complications have been reported. Methods: From January 2000 to December 2013, all charts of the pediatric patients who underwent laparoscopic appendectomy in our tertiary center were revised. The data from 1736 appendectomies were analyzed. We only included those patients with perforated appendicitis treated with early appendectomy (n = 192). Prophylactic drains were established according to the surgeon’s preference. The sample was divided into two groups, those with drain (n = 117) and those without drain (n = 75). Demographics, operative findings, and postoperative outcomes were analyzed in both groups. Results: Of all patients, 121 were male and 71 were female with a mean age of 7.77 ± 3.4 years. There were not statistically significant differences between the groups in gender (p = 0.82) and mean age (p = 0.31). There were no statistically significant differences between the two groups in the rate of intra-abdominal abscess, wound infection, and bowel obstruction. However, the drainage group has been statistically associated with an increased requirement of antibiotic and analgesic medication, fasting time, operative time, and length of hospital stay. Conclusion: The prophylactic use of abdominal drainage after laparoscopic appendectomy for perforated appendicitis in children does not prevent postoperative complications and may be associated with negative outcomes. Prospective randomized studies will be necessary to verify this question.

The pneumoperitoneum induced during laparoscopy has cardiovascular and respiratory effects that have to be taken into account to perform laparoscopic procedures in neonates and small infants. The aim of this paper is to describe the hemodynamic and ventilatory changes that occur in a group of these patients undergoing standard laparoscopic procedure. We performed a retrospective review of patients undergoing laparoscopic pyloromyotomy in our institution. We collected demographic data, data from the intervention, outcome and complications and hemodynamic parameters (heart rate--HR--and blood pressure--BP--) and respiratory (O2 saturation--SO2--and exhaled CO2--ECO2--) at different times during surgery. We performed statistical analysis of these data. We reviewed a total of 55 charts. Mean age was 34 days and average weight 3,785 g. All patients were ventilated with pressure control mode and received maintenance fluid therapy. BP, HR and SO2 were stable throughout the surgery not showing significant differences. The ECO2 increased significantly after inflation, however it was controlled by increasig respiratory rate. In conclusion, the hemodynamic and ventilatory response in these patients is controllable with anesthetic and surgical measures but it is important to consider the possible consequences of pneumoperitoneum in this group of patients.

INTRODUCTION:Pectus carinatum (PC) is a deformity that involves the protrusion of the anterior chest wall. It is 10 times less frequent than pectus excavatum. It has a progressive growth and is more common with men. There are two different types, the lower or condrocorporal which is the most common one, and the upper or condromanubrial. Most of the time there are no cardio-respiratory symptoms.OBJECTIVE:We present our experience in the orthopedic treatment of the pectus carinatum.METHOD:Retrospective review of patients treated in our hospital from 2002 until 2009. Patients were treated with observation, aerobic exercises, postural change and/or compression braces. Literature review was performed of the treatment for this pathology.RESULTS:18 patients have been diagnosed with PC, 16 were men and 2 women. All were treated in a nonoperative way. Only 11 of them used a compression brace. We missed two follow-ups and another has just yet begun to achieve proper results. All the rest have had excellent results with nonoperative treatment. None of them have had a surgical treatment.CONCLUSION:The PC is a disease that most often is a cosmetic problem, with no impact on a cardio-respiratory level. Classically it has been a surgical entity. In our experience we have found that the orthopedic method is an effective alternative, safe and with a significant reduction in morbidity. But we need the collaboration of the patient to accept and maintain continuity in the use of the prostheses.

The use of laparoscopy in patients with ventriculo-peritoneal shunts has been controversial. There is concern about the risk malfunction or infection of the shunt as well as about the possibility of adhesions that could make the surgical procedures too difficult to be undertaken by minimally invasive surgery. We present our results in pediatric patients with ventriculoperitoneal shunts that have undergone laparoscopic procedures in our department. We have performed 16 surgical procedures. The most frequent indication was fundoplication. During surgery there were no complications or intracranial hypertension episodes. Two of the procedures were considered by the surgeons more difficult and longer than usual. None of them required conversion to open technique. One shunt had to be replaced after surgery because of infection. According to our experience minimally invasive surgery is feasible and safe in pediatric patients with ventriculo-peritoneal shunts.

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.

INTRODUCTION:The inguinal hernia surgery is common in the pediatric population although laparoscopic management today, is not considered the standard technique. The aim of this study is to review the results of our study and evaluate the contralateral side in patients with unilateral hernia.MATERIAL AND METHODS:Retrospective study of laparoscopic herniorraphy at our hospital since the beginning of the art in 1999 with a total of 348 patients. The indications of laparoscopy have been the availability of umbilical hernia associated, doubt diagnosis, recurrence of open surgery, bilateral tumor and casual diagnosis. We analyzed the following parameters: sex, age, weight, associated diagnosis, intra and postoperative complications, recurrence and follow-up.RESULTS:474 hernias were repaired laparoscopically in 348 patients. A predominance of males against females (30%). In 37 patients (11%) the diagnosis was made during another operation. 39 patients with recidive open surgery were operated by laparoscopy. We had only 2% intraoperative complications and 2% of recurrences. The follow-up period is 10 years.CONCLUSIONS:Laparoscopic herniorraphy may be a routine procedure with results comparable to open surgery. Laparoscopy offers a good overview of the anatomy, easily identifying the defect, with a technique increasingly used in the field of pediatric surgery.

The investigation of a male with impalpable testes is one of the most frequent diagnostic indications of laparoscopy and it is accepted as a therapeutic tool for the treatment of the intra-abdominal testis. We have studied thirteen patients being surgically operated by a video-assisted orchidopexy without spermatic vessels section. The technique consists of wide mobilization of the spermatic vessels and the vas deferens from the posterior peritoneum, sectioning the gubernaculum and descending of the testis to the scrotum. In all the cases, the internal groin ring was later closed by means of a laparoscopy. There were no intraoperative complications. In 100% of the cases, the testis was descended to the scrotum. The surgical time oscillated between 40 and 80 minutes (60 minutes mean). At follow-up from 6 months to 4 years, the outcome was satisfactory in 11 patients, whereas in 2 cases the operated testis ascended.

INTRODUCTION:Congenital tracheomalacia (CTM) is a rare disease causing tracheal wall collapse when breathing. Herein, we show our experience in the management of this type of airway anomaly, settling the indications for surgical or endoscopic treatment.PATIENTS AND METHODS:We have performed a retrospective study, from 1991 to 2003, of patients with a bronchoscopic diagnosis of CTM or bronchomalacia (BM). We have analyzed the following facts: sex, age, indication of the initial bronchoscopy, ethiology, clinical group, anatomic type, associated malformations, treatment modality, complications, results, and time of follow-up.RESULTS:46 patients have been included in this study: 25 boys (54%) and 21 girls (45%). Mean age at diagnosis has been 11 months. The indications for diagnostic bronchoscopy have been: respiratory distress (24%), lung athelectasia (24%), stridor (21%), congenital tracheoesophageal fistula (11%), extubation failure (11%), apneic spells (6%), and recurrent pneumonia (2%). Secondary CTM has been much more frequent (82%) than the primary type (17%). Patients have been classified into 3 groups according to the severity of symptoms: group I--mild symptoms (7 patients); group II---moderate (22); and group III, severe (17). Tracheomalacia was diagnosed in 26 cases (56%), bronchomalacia in 12 (26%) and tracheobronchomalacia in 8 patients (17%). Almost all the patients (95%) have showed other associated malformations. Medical treatment has been instituted in 29 patients (63%), 15 cases (32%) have been managed surgically or endoscopically, and in 2 cases no treatment was tried because of their critical clinical status. In addition, in 17 patients (37%) an antireflux surgical procedure was performed. Satisfactory results have been achieved in 72% of treated patients, fair results were obtained in 4 (9%), and a poor outcome occurred in 2 (4,5%). Another 8 patients have died during follow-up due to unrelated causes. 36 patients (78%) are alive with a mean follow-up period of 5,3 years.CONCLUSIONS:Most patients with CTM can he treated conservatively though spontaneous resolution may he expected after the first year of life. Surgical or endoscopical procedures are indicated in those patients with severe respiratory symptoms.

BACKGROUND/PURPOSE:Stenosing airway disease, including congenital and acquired lesions, is rare in the pediatric age group. Until recently, the outlook for patients with congenital tracheal stenosis (CTS) was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. This report reviews the short and long-term outcomes of a single-institution experience in the management of CTS in children, comparing different treatment modalities.METHODS:From 1991 to 2002, 13 cases of CTS have been managed in the authors unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy established the diagnosis in all cases. According to clinical and endoscopical features, patients have been classified into 3 groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomic type, associated anomalies, treatment modality, complications, outcome, and time of follow-up.RESULTS:Seven girls and 6 boys have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 8 months), and 77% showed associated anomalies. Four patients presented mild or no symptoms and have been treated expectantly. The other 9 patients have been operated on because of persistent or severe symptomatology. The following procedures have been performed: costal cartilage tracheoplasty (n = 5), tracheal resection (n = 3), slide tracheoplasty (n = 2), endoscopical dilatation (n = 3), and laser resection (n = 1). Three patients required 2 or more procedures, and there were 3 early deaths, all after costal cartilage tracheoplasty. Overall mortality rate in the series is 23%. Follow-up is complete in all survivors (n = 10) ranging from 6 months to 10 years (mean, 4.7 years).CONCLUSIONS:Selection of the type of treatment depends on the patient's clinical status and the anatomic pattern of the stenosis. In symptomatic cases of short-segment stenoses the authors prefer tracheal resection with end-to-end anastomosis; for long-segment stenoses, slide tracheoplasty is the procedure of choice.

Stenotische Luftweg-Erkrankungen, mit angeborenen und erworbenen Läsionen, fallen unter eine seltene Gruppe im Kindesalter. Bis vor kurzem war die Zukunft für Patienten mit angeborener Tracheal-Stenose (ATS) mit sehr wenig Hoffnung, da eine medizinische Behandlung der einzige Ausweg dieser Erkrankung war. Chirurgische und endoskopische Techniken entwickelten sich in den letzten Jahren und verbesserten die Prognosen der Heilung.

Superior mesenteric artery syndrome (SMAS) is a rare condition characterized by recurrent vomiting, abdominal distention, weight loss, and postprandial distress. The cause is compression of the duodenum between vessels and the vertebrae and paravertebrae muscles when the angle between the superior mesenteric vessels and the aorta is lower than 18°. The diagnosis is difficult and usually is made by exclusion. Conservative management is helpful at first; however, symptom recurrence would indicate surgical treatment. We recently treated a patient with SMAS. After extraction of a stomach bezoar by laparotomy, an upper gastrointestinal series suggested duodenal distention and a filling defect in the region of the superior mesenteric artery. Repeated ultrasonographic and abdominal CT scans showed a lateral pulsatile compression in the region of the distal duodenum, and SMAS was the diagnosis. Laparoscopic severing of Treitz's ligament was performed. The operation was successful, recovery was uneventful, and the patient has been asymptomatic for 1 year. The weight loss seen preoperatively has been corrected. We conclude that the laparoscopic division of the ligament of Treitz with a 5-mm instrument is a safe and efficient way to free the duodenum and move the duodenojejunal flexure downward. In our opinion, this procedure is the treatment of choice for this condition.

A 1-year-old girl presented with fever, asthenia, and splenomegaly with hypersplenism. Abdominal ultrasound scan and magnetic resonance imaging showed multiple nodular cystic masses in an enlarged spleen. The histological examination of the resected spleen showed a novel type of vascular tumor called littoral cell angioma. The histopathologic and immunohistochemical features of this rare lesion are described. Distinction from other splenic vascular tumors is stressed because the clinical behavior of this new entity seems to be benign. J Pediatr Surg 35:508-509. Copyright © 2000 by W.B. Saunders Company.

From 1982 to 1994, 1.003 cases of surgical newborns have been retrospectively studied. Frequency and epidemiology have been evaluated, so as associated malformations. Prenatal diagnosis was made in 72 cases (7.1%). The most frequent entity was intestinal atresia, with 122 cases (12.1%), followed by necrotizing enterocolitis in 80 cases (7.9%), nevertheless this last one was the most frequent finding in preterm newborns. Esophageal atresia was found in 57 cases (5.6%). Association with other malformations was found in 127 cases (12.6%), and 32 cases of them (3.1%) constituted congenital malformations syndromes. The number of surgical newborns has increased in the last years, mainly due to ambulatory surgery. Global mortality of operated patients was 62 cases (5.9%); the highest mortality index was for congenital diaphragmatic hernia (33.5%), followed by necrotizing enterocolitis (28%). Mortality rate has decreased in recent years, due to improving in management and treatment of these patients, and the consolidation of surgical newborn units. Future efforts should be aimed for decreasing in mortality and improving the standard of life of these patients.

Endoscopic variceal ligation (EVL) is an alternative technique to endoscopic variceal sclerotherapy (EVS) to treat esophageal varices. This method consists of mechanical ligature and thrombosis of varices using elastic rubber rings. During an 11-month period, nine pediatric patients with esophageal varices secondary to portal hypertension were treated by EVL. Extrahepatic portal vein obstruction was the cause of portal hypertension in 5 patients and in 4 cases the cause was intrahepatic disease. The average age of the patients was 8 years (range: 2-15). Five patients had bled from esophageal varices previously. Two were actively bleeding at the time of the procedure. Endoligature was performed prophylactically in four patients. Fifty varix ligations were performed in 26 separate sessions. In children older than ten years, EVL was performed under intravenous sedation. Two mild rebleeds have occurred in this group and responded to repeated ligature. Varices were reduced in grade in all patients. Six patients achieved variceal eradication. Recurrence of varices was not encountered. No major complications occurred and there were no treatment failures. These early results suggest that endoscopic ligation is a safe and effective method for the control of esophageal varices in children.

In October 1987 we opened an Outpatient Surgical Unit, since January 1988 to December 1993 we have treated 8232 patients with an mean age (range of 2 weeks to 17 years). All the patients were given general anesthesia, loco-regional anesthetics or deep sedation. 33.5 percent of the total number of patients operated in our hospital were treated in this Unit, being 41.4 percent if related to programmed surgery. Only 2.5 percent of them were admitted in the inpatient area with no significant complications.

Pancreatic pseudocysts is a complication of acute posttraumatic pancreatitis. They usually cause recurrent abdominal pain, nausea, vomiting and elevation of serum amylase levels. A history of epigastric blunt trauma, the before mentioned clinical signs and echographic or scanning studies may lead to a certain diagnosis. Although most of them resolve spontaneously, some persist and active therapeutic measures are required. Surgical internal drainage has been the operative technique of choice in children. Nevertheless, treatment can be achieved by percutaneous aspiration or drainage of pancreatic recurrent collections. We present our experience in two children with posttraumatic pancreatic pseudocyst, treated successfully by means of a percutaneous transabdominal pig-tail catheter (Huisman catheter). The technique of catheter placement and clinical aspects are discussed.

Hirschsprung's disease surgically treated with Duhamel's technique in which no mechanical suture has been used, usually presents, as main complication, cronic constipation, due to fecalomas in the rectal pouch. In our experience (30 cases plus four patients sent to our hospital for reintervention), this complication is not present when mechanical suture is introduced to the Duhamel's Technique. This allows us to assure that perineal rectocoloplasty, with auto-suture material is a precise optional treatment, with excellent results and allows the chance of not going through laparotomy in those cases that require reintervention.

During an 9-month period (March to November 1992), six children underwent an intestinal anastomosis by means of a biofragmentable ring (BAR). Patients ages ranged from 5 to 16 years old. There were no mayor complications at surgery. The main technical problems was the difference of size between BAR and intestinal lumen. No patients in which BAR was used have presented fistulae, dehiscence or anastomotical stenosis.