[Liver bipartition as an alternative to the transplant]

AIM

Liver pediatric transplantation finds in the lack of donors its main limitation. An alternative in those cases is split liver grafts from bigger donors.

PATIENTS AND METHOD

We performed a retrospective study of 56 hepatic split transplants performed between 1994 and 2007. Twenty-nine children were transplanted with a median age and weight of 1.8 years old (0.3-9) and 9.7 kg (6.2-23). In 16 cases (53.3%) liver transplant was performed in emergency situation. In one patient we performed a combined transplant (liver-kidney) and in another patient it was a second transplant due to primary graft failure after receiving an hepatointestinal allograft. Type of grafts used were: lateral left segment (n=26), extended lateral left segment (n=1) and extended right liver (n=3). Median donor age and weight were 20 years old (8-44) and 60 kg (24-80). We studied patient and graft survival (Kaplan Meier), perioperative factors, complications and net rate of early complications in adults recipients.

RESULTS

Patient survival was 96.7% after 6 months, 1 year, 5 years and 10 years. Id for grafs 86.7%. Two grafts were lost due to arterial thrombosis, one due to primary non function and another due to recipient death secondary to a sepsis. Five children had major biliary complications and 2 of them developed multiple intrahepatic stenoses, one of them being on waiting list for retransplant. Early graft lost (retransplant or death before leaving the hospital) occurred in 4 out of the 25 grafts transplanted in other centers (25 adults, 1 kid); all of them occurred in the initial period (1994-2001).

CONCLUSIONS

Even though it is clearly documented that benefit of transplant (measured in years of life won) is very good after split transplantation, nowadays criteria for organ allocation in Spain do not allow a more extensive diffusion of this technique and it is confined to urgent transplant. Even in those cases, results after split transplantation are excellent. Without this possibility our pretransplant mortality would be much higher.

[Liver transplant from living donor]

AIM

Even though Spain has the highest donation rate in the world, our needs cannot be satisfied, specially in younger children. Living-related donor transplant is an alternative in those cases.

PATIENTS AND METHOD

We performed a retrospective study of 57 living-related donor transplants performed in our hospital between June 1993 and December 2007. Median age and weight were 1.2 years old (0.5-14.8) and 8.5 kg (5-62). Indications for transplant were as follow: biliary atresia in 42 cases (73.7%), hepatic tumor in 8 (14%) and others in 7 patients. Type of graft was: monosegment (n=1), left lateral segment (n=45), extended left lateral segment (n=5), left liver (n=4), right liver (n=2). We studied the following factors: graft and patient survival (Kaplan Meier), perioperative conditions, complications, causes of graft lost, donor complications and technique difficulties.

RESULTS

Patient survival at 3 months, 1 year, 5 years and 10 years was 98.2%, 98.2%, 95% and 95% respectively. Three grafts werelost due to arterial thrombosis, two due to rejection, one due to portal thrombosis and three due to other causes. Complications were as follow: biliary fistula in the cut surface (6), biliary anastomosis complications (6), cut surface abcess (1), portal stenosis (2), suprahepatic stenosis (1) and intestinal perforation (2). Most common complication in donors was biliary leak (4). Among the technique difficulties, 8 patients needed major reconstruction of suprahepatic vein; 4 needed complex portal reconstruction, 6 patients had double biliary tract and 4 patients needed multiple arterial anastomosis. Wall closure was delayed (Goretex) in 35% of cases (20).

CONCLUSIONS

Despite technical complications, results after living-related donor transplantation are excellent. It is particularly favourable for children with low weight, since Spanish policy for organ allocation does not make easy to find an adecuate donor in short periods of time. Without living-related donor transplantations, mortality pretransplant would be much higher.

Variant techniques for liver transplantation in pediatric programs

INTRODUCTION

Several variant techniques have been developed as alternatives to whole liver transplantation to improve size matching, timing, or simply to increase the pool of donors. The aim of this study was to assess the requirements of these techniques and their outcomes in a pediatric transplant program.

PATIENTS AND METHOD

A retrospective analysis of children on the waiting list in the last 4 years was carried out. Data of patients who died while on the waiting list (WL) were recorded. Transplanted patients were divided according to the type of graft: whole liver, split, living donor and reduced liver. The analyzed outcome variables were: age, weight, UNOS status, cause of liver failure, complications and graft and patient survival. Comparisons between types of graft were performed by using Kaplan-Meier, log-rank, chi (2) and Kruskal-Wallis tests.

RESULTS

During the period studied, 116 children were listed for liver transplantation. Of these 116 children, nine (7.7 %) died after a mean period of 40.5 (5-175) days waiting for a suitable graft. Their median age at inclusion was 214 (35-1607) days, and median weight was 7.2 (12.3-3.6) kg. The cause of liver failure in this group was: 1 hemochromatosis, 1 hepatoblastoma, 2 biliary atresia, 2 acute liver failure, 2 primary non-function (PNF) and 1 chronic rejection. Liver transplantation was performed in 103 children: 25 (24 %) whole livers, 17 (16.5 %) split, 29 (28 %) living donor, 32 (31 %) reduced and 4 remain on the waiting list. Recipient age and weight were significantly lower in those receiving split and living donor than in those who given whole livers. Patient and graft survival were similar in all groups although there was a trend to lower graft survival in patients receiving whole livers. More than 50 % of patients with UNOS status I received a split graft and 5/6 children with hepatoblastoma underwent living donor transplantation. There were no differences in the rate of acute vascular complications, but long-term biliary complications were more frequent in split and living donor grafts.

CONCLUSIONS

As long as the goal of zero mortality for children on the waiting list is not achieved, variant techniques will be necessary in pediatric liver transplantation programs. Split and living donor were employed mostly to treat younger children and particularly those with a higher UNOS status. Children with tumors were treated mainly with living donor grafts. Variant techniques, which are absolutely necessary in a pediatric program, need to be improved in order to avoid long-term biliary complications.

[Liver transplatation for malignant tumors in children]

OBJECTIVE

To analyse our results on liver transplantation (LTX) in primitive malignant unresectable liver tumours in children and discussing its controversial indications in order to our experience.

METHODS/PATIENTS

We report 12 patients with ages ranging from 6 months to 14 years old. They had hepatoblastoma (11) and fibrolamellar hepatocelullar carcinoma (1) without cirrhosis. LTX was considered as primary treatment in 10 patients (PRETEXT IV or any grade if extension to retrohepatic cava vein, 3 hepatic veins or porta vein were assessed) and as rescue therapy after recurrence (1) or persistence of unresectable macroscopic rests (2). One of the patients who underwent a LTX as primary therapy had lung metastases previously resolved with chemotherapy. We used entire liver (5), left lateral segment from cadaveric donor (3), live related donor (3, 2 segments II-III and 1 right liver) and left lateral segment from split (1). All children received chemotherapy prior and post-transplantation following SIOPEL protocol. OUTCOMES ANALYSED: Procedure tolerance, survival, recurrence rate, disease-free period and risk factors for adverse evolution.

RESULTS

All patients overcame the LTX and no early loss of the graft was assessed. 2 patients died because of tumoral relapse, 1 after primary LTX and 1 after rescue LTX (survival rate of both groups 90% vs 50%). Graft and patients 1-year, 3-year, 5-year and 14-year survival were 91%, 91%, 82% and 82% respectively. The boy who presented lung metastases developed new ones one year after LTX that were removed and he actually is free of disease. The disease-free period has a probability for 1, 3 and 5 years of 91%, 75% and 75%. Tumoral tissue persistence is the only risk factor for an adverse evolution in our series.

CONCLUSIONS

LTX is possible therapeutic approach for unresectable malignant liver tumours. It provides better results as a primary treatment than as a rescue one, being these outcomes comparable to those from resectable tumours. A right staging and referring patients to an expertise centre contribute to optimize results. LTX for patients presenting with lung metastases could be a controversial option. Live-related donor transplantation is an excellent alternative to avoid disease progression during cadaveric waiting list.

Sternal cleft associated with enterogenous cyst treated during the newborn period

We present the case of a newborn with sternal cleft (SC) and presternal enterogenous cyst operated on during the neonatal period. SC is an uncommon congenital malformation of the thoracic wall which can occur as an isolated form or in association with other malformations. To our knowledge, the presence of SC and enterogenous cyst has not been described to date. Early surgical repair of SC gives good aesthetic and functional results and is usually the preferred approach.

[Orthotopic liver transplantation in children younger than one year]

BACKGROUND

Orthotopic liver transplantation (OLT) in children younger than one year is associated to higher waiting list mortality and alternative graft sources are required. We present our experience with this particular group of age.

METHODS

Infants younger than one year who received an OLT between 1986 and 2005 were reviewed focused on graft and children survival depending on period and type of graft. Periods were 1:1986-1995; 2:1996-2000 and 3:2001-2005. We also evaluate cold ischemia time (CIT), graft lost causes and differences between CIT and anhepatic time (AT) depending on graft type.

RESULTS

Eighty-three children received 103 OLT. Liver transplant indications were 59 (72%) biliary atresia, 8 (10%) metabolic causes, 6 (8%) liver failure, 3 (4%) cirrhosis and 7 (6%) miscelaneous. Patient and graft survival after 5 years was increased depending on period: 45% and 65% on period 1, 70% and 80% on period 2, 94% y 97% on period 3 (p < 0.0198). Thirty-seven grafts were reduced lobes (42%); 8 (21%), 17 (45%) and 12 (35%) during periods 1, 2 and 3 respectively and their 5 years survival rate was 68%. Twenty-four were whole grafts (31%); 11 (45%), 10 (45%) and 3 (14%) during periods 1, 2 and 3 and their 5 years survival rate was 63%. Fourteen grafts were living-related donor (16%); 1 (7%), 2 (14%) and 11 (79%) during periods 1, 2 and 3 and their 5 years survival rate was 93%. Eight (11%) were split; 0, 1 (12%) and 7 (90%) during periods 1, 2 and 3 and their 5 years survival rate was 100%. Average CIT depending on graft was: living donor 5,5 hours (IQR: 4-7), split 6,1 hours (IQR: 5-8), whole 9.2 hours (IQR: 6-11) and reduced 8.5 hours (IQR: 6-11) (p < 0.05). Average AT depending on graft was: living donor 1 hour (IQR: 0.5-1.5), split 1 hour (IQR: 0.5-1.4), whole 1,1 hours (IQR: 0.5-1.5) (p > 0.1). Twenty-four grafts were lost (28%): 10 (41%) were surgical related causes and 6/10 (60%) of them were whole grafts.

CONCLUSIONS

Survival rates in children younger than one year are similar to another groups of age. There was a significant increase on graft survival according to transplantation group experience. A higher rate of graft lost is associated to whole grafts. Most frequent reasons of graft lose were related to sepsis and immunosuppresion. A significant shortening of CIT is observed in related living donor and split grafts.

[Surgical treatment in severe dog bites injures in pediatric children]

INTRODUCTION

We report a retrospective study of dog-bitten-children who underwent surgical treatment in our department between 1995 and 2005. We checked the different surgical techniques used to cover the defect as well as short and long-term functional and aesthetic results, considering also infection and hospital stay.

MATERIALS AND METHODS

During this period of time, 21 patients received surgical treatment because of dogs bites. Surgical approach was decided considering location and severity of lessions.

RESULTS

Our serie consists of 12 males and 9 females. Head (71%) and extremities (23%) were the most frequent affected areas. Primary closure was carried out in 18 cases and in the remaining 3 artificial skin or tissue flaps were needed; in these 3 cases the resulting scar was later removed. Surgical infection occurred in less than 10% of the children and in all cases, long-term aesthetic results were considered excellent.

CONCLUSIONS

Primary closure of dog-bites-injures improves functional and aesthetic results and reduces the surgical procedures in those patients.

[Pediatric patient in adult age. Long-terms results of esophageal replacement]

BACKGROUND

Esophagocoloplasty is one of the most used procedures for esophageal replacement in children. Considering high life expectancy in these patients, long-term results must be considered when evaluating this technique. The aim of our study is to evaluate quality of life of adult patients who underwent surgery at pediatric age.

PATIENTS AND METHODS

We report a retrospective study of 99 patients who underwent esophageal replacement in our institution between 1966 and 2006. Eight of them have died and 63 out of the remaining 91 are over 18 years now and represent our study serie. Long-term results and actual situation of those patients, considering psychological, physic and social aspects, were evaluated through clinical review and telephonic interview. Karnofsky index was applied to mesure functional ability from 0-100% (bad, medium, good-excellent) according to the answers the patients gave to our questions. We also recorded their health personal experience and subjective evaluation of their quality of life.

RESULTS

Sixty-three patients were reviewed (43 males and 20 females) with a mean age of 4.3 +/- 3.4 D.S. Mean follow-up time was 29.6 +/-7.7 years. Indications for esophageal replacement were as follows: caustication (n = 32), type III esophageal atresia (n = 15), type I AE (n = 13) and others (n = 3). In 48 patients the graft was placed in retroestenal position and in 15 cases retromediastic location was used. Postoperative period was uneventful in 44% of the patients, being the most frequent early complications in the remaining, cervical leakage and stenosis. Long-term, 56,8% did not have any sequelae, 28.5% required further surgery and the remaining 43.13% presented the following complications: symptomatic graft reflux (22), scoliosis and thoracic asymmetry (12), colonic redundancy or cervical diverticulum (7), food impaction (6) and failure to thrive (5). Only one 38 year old patient does not have intestinal tract continuity nowadays. Thirty-one patients have a Karnofsky index > or = 80-100%, being considered healthy and able to have a normal activity. Eighteen patients are included between 40-80%, being the most frequent limitation the need of medication to avoid reflux, backache and occasional episodes of food impact. Only 2 patients have Karnofsky index inferior to 40%. None of them are under 20%.

CONCLUSIONS

Esophagocoloplasty allows restoration of intestinal tract continuity in almost all cases and the mortality of this procedure has decreased over time. Even though some risks are still remarkable, it offers long-term good results with little repercussion on functional ability in adult age. Most of the patients consider themselves healthy and enjoy an acceptable quality of life.

[Aplasia cutis congenita: surgical treatment and results in 36 cases]

INTRODUCTION

Aplasia cutis congenita is a rare congenital absence of skin most commonly affecting the scalp. Although most defects are small and superficial, approximately 20% of cases involve absence of the skull. Such defects expose the brain and sagital sinus, with concomitant risk of fatal hemorrage, infection, or both. This anomaly most commonly presents as a solitary defect, but sometimes it may occur as multiple lesions. The lesions are noninflammatory and well demarcated, and range is variable from 0.5 cm to 10 cm or more. Although the majority of these scalp defects occurs sporadically, many family cases have been reported. Multiple causes have been suggested for aplasia cutis: genetic causes, syndromes and teratogens, intrauterine infection -varicella zoster virus, herpes simplex virus-, fetal exposure to cocaine, heroin, alcohol or antithyroid drugs.

MATERIALS AND METHODS

A retrospective study of children with Aplasia Cutis Congenita who received treatment in Hospital La Paz, in Madrid between 1995 and 2005 was undertaken. We checked location, moment of the surgery, type of surgery and aesthetic results.

RESULTS

In the 20 year period between 1985-2005, we treated 36 patients with Aplasia Cutis. 33 of them have the scalp affected and only in 3 cases the trunk was involved. In 4 cases there was an absence of the skull, two slight and two severe. 3 patients had Adams-Oliver and one Cutis Marmorata Telangiectasica syndrome. Fifteen patients were operated in neonatal period with direct closure or advancement or rotational flaps, and in 17 cases the late treatment included use of tissue expanders to cover definitely the defect. One of the patients died for bleeding of the sagital sinus while was waiting for the secondary closure of the wound, and other patient required complex skull reconstruction to achieve a complete coverage.

CONCLUSIONS

In view of our experience and results, we believe that early surgery prevents vital risks, reduces local complications and makes easier the final reconstruction.

[Early surgical treatment in nasal tip hemangiomas: 36 cases review]

BACKGROUND

Hemangiomas are the most common benign tumours in infancy. Its trophoblastic origin is now confirmed and it would explain their increasing incidence that runs parallel to the more frequent use of fertilization in vitro techniques and the high rates of prematurity and twinning. It is not a coincidence that they appear more often in the face and its location is related to the merging lines of the facial embryonal buds. Nose tip, upper-eyelid and orbital regions are special areas that need a different approach in each case. Over the last years we changed our therapy protocol for these tumours, in an attempt to decrease the psychological, social and scholar impact in children.

PATIENTS AND METHODS

During the last 20 years, 36 patients with nasal tip hemangiomas underwent surgical treatment in our institution. We divided them into two groups, those treated between 1985 and 1992 (n=l1) and those treated between 1992 and 2005 (n=25). Traditionally, conservative management including close observation, corticosteroid therapy and finally surgical treatment of the sequelae, was proposed. Late surgical treatment was reserved for incompletely regressed or unsuccessfully treated facial tumours. Our more recent approach involves early surgical excision, in order to avoid psychological distress and cosmetics defects. Age at diagnosis, appearance at that moment, sort of treatment and time of surgical procedure were recorded to evaluate long-term results.

RESULTS

In this paper we report our series of 36 patients, consisting of 26 females and 10 males, with a mean age of 5 +/- 2 months at the first visit. In 11 patients from the first period (1985-1992), corticosteroid therapy was applied waiting the spontaneous regression and they finally underwent delayed surgical treatment at a mean age of 8 years. In the remaining 25 patients treated in the second period, early surgical excision was carried out with a mean age of 3 years and before school age. Indications for corticosteroid therapy include uncontrolled growth and complications (ulceration).

CONCLUSIONS

The approach to management of nasal tip hemangiomas should be individualized and must take into account their depth, location, rate of involution and functional disturbance. Children age as well as psychological problems arising from the presence of proliferative hemangioma must be considered when deciding a surgical approach. Upon the high rates of scholar failure in children with deforming hemangiomas, the lack of response to medical therapy and the need of surgical treatment in all cases, our policy now it is to attempt surgical excision and reconstruction before school age. Based on data reported and on our own experience, we consider that very early surgical treatment improves quality of life of our patients and their families.

[Multidisciplinary approach in the management of intestinal failure]

OBJECTIVE

[corrected] Our aim was to analyze our results in the management of intestinal failure with a multidisciplinary approach including optimized parenteral nutrition, reconstructive surgery and intestinal transplantation (ITx).

MATERIAL AND METHODS

We included all patients evaluated by our team with the diagnosis of IF. We assessed outcome, mortality and complications in children that achieved adaptation and those listed for ITx.

RESULTS

Seventy one children (40 boys, 31 girls) were evaluated between 1997 and 2006 because of IF. Forty eight (76%) were referred from other institutions. In 56 cases (80%) IF began in the newborn period. Causes of IF were: short bowel syndrome (52) intestinal motility disorders (16) and intestinal epithelial disorders (3). Median birth weight in the group of SBS was 2.2 Kg and prematurity was an associated condition in 15% of them. Overall, fourteen patients (20%) achieved intestinal adaptation with progressive weaning from PN, the management of these children consisted of optimized parenteral and enteral nutrition and autologous intestinal reconstructive surgery. Nine (13%) are stable under home parenteral nutrition regimen. Eight children (11%), all of them listed for liver and small bowel transplantation, died in the waiting list after a mean waiting time of more than 300 days, with a median of 4 laparotomies and 4 episodes of catheter related sepsis. Four children (5.6%) died in the adaptation process or before their inclusion on the waiting list. Finally, twenty five (35,2%) children underwent 28 intestinal transplantation: 9 isolated small bowel transplantation (SBTx), 16 combined liver and small bowel (CLSB) and 3 multivisceral (MVTx). Among transplanted patients, 9 (36%) died, (3 MVTx, 1 SBTx and 8 CLSB) and four were retransplanted.

CONCLUSIONS

Intestinal Transplantation is an established alternative to parenteral nutrition in the treatment of IF, although complications and mortality rates are still considerable, especially MVTx and CLSBTx. Mortality in children listed for intestinal transplantation remains also high. Intestinal adaptation can be achieved with adequate rehabilitation therapy even in some cases with apparently irreversible intestinal transplantation. Early referral before liver failure or other complications arise is crucial is crucial in order to improve the outcome of these patients.

[Congenital cystic adenomatoid malformation: prenatal diagnosis, surgical treatment results and long-term follow-up]

PURPOSE

(PD), possibility of regresion and hidden mortality are open questions in congenital cystic adenomatoid malformation (CCAM) treatment.

METHODS

Children with CCAM were reviewed focused on: PD, postnatal diagnosis, clinic, radiology, histology and evolution.

RESULTS

Seventeen fetus had PD of CCAM. Five gestations were electively finished (41%) with PD of CCAM previous to 20th week, 3/5 (60%) were type III and 2/5 (40%) type I; 4/5 (80%) presented mediastinal shift and 1/5 (20%) hidrops. Two fetuses (11%) suffered fetal demise in 20th and 32th week; 1 type 1 and 1 type III; 1/2 (50%) presented hidrops and 2/2 (100%) mediastinal shift. Two (12%) died before 24 hours after birth without intervention possibility due to respiratory instability, 1 type II and 1 type III, both with mediastinal shift (100%). In one fetus with a type III malformation the image disappeared completely in 32th week and no intervention was done. Fourteen patients were operated (8 girls and 6 boys); 7/14 (50%) had PD, average diagnosis week was 21.9 (range 19.1-35.5), 5/7 (71%) was type I, 1/7 (14%) type II and 1/7 (14%) type III. None had mediastinal shift or hidrops. Average postnatal diagnosis week was 7 months (range 0.1-29). In 10/14 (71.4%) there were not respiratory difficulty during neonatal period and 3/10 (30%) suffered respiratory infections afterwards. Average week of operation was 8 months (range 0.1-30). PD was according with histology in 6/7 (86%) patients. After an average follow-up period of 4.3 years (range 1-9.5) the only complication is a pectus excavatum.

CONCLUSIONS

More than half of patients with PD of CCAM died without intervention. Half of cases of CCAM are diagnosed prenatally. Type of CCAM in PD is according to histology in 86% of the cases. Fetuses with hidrops present a worse prognosis. Surgical timing do not seem to influence on outcome.

[Complex lymphatic malformations: diagnostic and therapeutical implications]

BACKGROUND

Complex lymphatic malformations (CLM) consist of disturbances of lymphatic system development, most often with a genetic origin and with mixed vascular system involvement: lymphatic, venous and capillary. They affect a large corporal area or are associated to other syndromes or systemic diseases.

METHODS

We reviewed 21 patients with CLM treated in our hospital during the last 15 years. We used D2-40 monoclonal antibody (by immunohistochemistry) as lymphatic marker to evaluate the level of lymphatic involvement. Furthermore we analysed surgical implications in this group of patients.

RESULTS

Twelve children had only lymphatic involvement and nine mixed lymphatic-capillary or lymphatic-venous one. Two died of: respiratory insufficiency (in the neonatal period) and refractory hypoproteinemia (at 8 years of age). The skin was affected between 10 and 35% of total body surface. Three patients suffered from visceral involvement (lungs and mediastinum) and eighteen musculoskeletal. Severe deformity (20), lymphorhagia (15), repeated lymphangitis and chronic pain (5) were the most common symptoms reported. The immunoreaction intensity with monoclonal antibody D2-40 was related to the severity of the local and systemic involvement as well as to the presence of associated malformations. Fifteen cases underwent sequential surgical treatment, seven were treated with sclerotherapy (OK-432) and four with CO2 laser vaporization. Residual lymphorhagia in patients with total extirpation of the lymphatic malformation stopped after repeated evacuator punctures and healing took place.

CONCLUSIONS

(1) D2-40 monoclonal antibody is a marker of bad prognosis in CLM. (2) The complete excision of the lymphatic malformation lead to healing and the associated lymphorragia should not be considered as a recurrence, which will stop with evacuator punctures in all cases. (3) A multidisciplinary team approach is essential for the proper care of CLM in order to minimize postoperative sequelae and late complications.

Pediatric surgeons and gastroesophageal reflux

BACKGROUND/AIMS

Better antacid medications and the introduction of laparoscopy destabilize the indications for fundoplication. This study aims at raising a discussion among pediatric surgeons on these indications, modalities, and the results of this operation.

MATERIALS AND METHODS

A total of 252 refluxing children operated between 1992 and 2006 were divided into groups according to predominant symptoms (93 digestive, 47 respiratory, and 68 neurologic) or to comorbidities (27 esophageal atresia, 10 diaphragmatic hernia, 5 abdominal wall defects, and 2 caustic stricture), and the indications, complications, mortality, and long-term results were reviewed. Features of open (n = 135) and laparoscopic (n = 117) approaches were compared, and long-term integrity of the wrap was analyzed using the Kaplan-Meier method.

RESULTS

Digestive, respiratory, and neurologic patients had more often laparoscopic plications, whereas all others rather had an open approach. The rate of complications was 22%, and they were more frequent in children operated by laparotomy (P < .05). Median follow up was 51.3 months (range, 6-160). Overall wrap integrity was maintained in 89% of the children, and the proportions for digestive, respiratory, and neurologic groups were 95%, 95%, and 87%, respectively. For esophageal atresia, congenital diaphragmatic hernia, abdominal wall defects, and caustic stricture, they were 72%, 77%, 100%, and 0%, respectively. The functional results were fully satisfactory in 83% of patients. There were 17 deaths (6.7%), but only 3 in the first postoperative month and only 1 related to the operation (0.4%).

CONCLUSIONS

Fundoplication is a powerful method of reflux control. It is indicated after failure of medical treatment in gastroesophageal reflux disease and in symptomatic refluxers with some particular comorbidities. Surgery should be offered only after diagnosis has been firmly established, and the indications must remain identical for open and laparoscopic procedures. High technical standards and rigorous report of the results are required for keeping a relevant place of pediatric surgery in the treatment of this disease.

[What can we do when a esophagocoloplasty fails?]

BACKGROUND

Postoperative complications of esophageal replacement are potentially severe, and they can even make impossible the digestive continuity. However, several surgical options have been used for such situations. The aim of the study is to assess the early and late results in patients who have been managed or referred to our department for this problem.

PATIENTS AND METHODS

We reviewed 8 patients operated between 1975 and 2005, four of them were referred from other hospitals. The ranging in age was from 4 months and 23 years at the moment of the first colonic replacement, and who required a second plasty because of intra or postoperative complications. The esophagocoloplasty was retrosternal in 6 cases and transhiatal in 2, with a left colon graft in 6, ileocolonic in I and right colon in the last one. The initial diagnosis was traqueoesophageal fistula in 6 (type III in 3, type I in 2 and IV in 1), caustic injury in 1 and herpetic esophagitis in 1. Complications requiring reoperation were stricture of the cervical esophagococolic anastomosis because of postoperative dehiscence (n=4), perioperative deficient graft vascularisation (n=2), graft necrosis (n= 1) and symptomatic gastric-colic reflux (n=l).

RESULTS

The deficient graft irrigation was detected and managed during the surgical procedure in 2 cases, left colonic graft was remplaced by a gastric tube and the right colon, respectively, with excellent results. Repeated endoscopic dilatations (n=4) as well as surgical revision with resection and reanastomosis of the stenotic segment (n=2), did not suffice in children with severe strictures (100%). A second plasty was tried in 2 patients: a failed microsurgical sigmoid graft in one of them, and a presternal esophagocoloplasty with a left colonic graft in the other one. It was impossible to perform a new plasty in two chidren, because of the severe mediastinal fibrosis. One patient was referred with severe gastro-colic reflux and the cologastric anastomosis and the gastrostomy were refashioned. Another patient with graft necrosis required total resection of the coloplasty and a new esophagostomy and gastrostomy. 50% of the patients recovered digestive continuity, and nowadays three of them eat normally. The fourth one died after several years because of an Guillain Barré syndrome. Four patients are still waiting for future attempts of esophageal substitution.

CONCLUSIONS

There are surgical options to reestablish the digestive continuity whenever the initial esophageal replacement fails. Severe postoperative strictures do not dissapear with endoscopic dilatations or stenotic resection and reanastomosis, but they usually require a new graft in another less injured place. Poor vascularisation of the graft can be prevented, giving the best solution for each patient, and at minimal suspicion of ischemia, consider another plasty or access during the operation.

Non stenotic food impaction due to eosinophilic esophagitis: a potential surgical emergency

AIM

Eosinophilic esophagitis (EoE) is an emergent condition in which a mucosal infiltrate of > 20 eosinophils per high power microscopic field is accompanied by motor disturbances that may cause food impaction in the absence of esophageal stricture. We report a series of such cases to point out the potential involvement of pediatric surgeons in diagnosis and treatment. Furthermore, data on the motor function of the esophagus investigated manometrically is included.

MATERIAL AND METHODS

Thirteen patients with EoE were referred to our emergency room for acute food bolus impaction. Their median age at diagnosis was 12 years (range 7.6-14.4). History of allergy, endoscopy with biopsy and esophageal function (24-h combined ambulatory manometry with simultaneous pH-metry) were investigated.

RESULTS

In 7 patients emergency endoscopic extraction of the impacted bolus was necessary. Allergic tests were positive in eight patients. The pH probe showed gastroesophageal reflux in two cases. Upon endoscopy, typical features of EoE (esophageal trachealization and whitish papular exudates) were found. Ambulatory 24-h manometry revealed abnormal motility of the distal esophagus with strikingly high amplitudes (> 150 mmHg) and long duration (> 7 sec) of the waves, particularly during the night. Six patients responded rapidly to steroids and/or antiallergic treatment. The remaining patients had a good outcome with dietary treatment alone.

CONCLUSIONS

EoE is an emergent condition that may involve the pediatric surgeon in both the diagnosis and treatment. Typical endoscopic findings and biopsy are required for proper diagnosis. Ambulatory manometry reveals a marked propulsive dysfunction that explains impaction. This dysfunction is reversible, since the symptoms usually disappear with steroids or antiallergic treatment.

Nutritional status after intestinal transplantation in children

INTRODUCTION

The management of children receiving small bowel grafts involves potentially life-threatening complications that affect their nutritional status. The aim of this paper was to define these factors and their influence on nutritional outcome.

PATIENTS AND METHODS

Patients with intestinal failure (IF) who received an isolated small bowel transplantation (SBT) or small bowel/liver transplantation (SBLT) at our hospital during the last 6 years were reviewed for weight Z-score, biochemical nutritional parameters, total parenteral nutrition (TPN) weaning, catheter-related sepsis, rejection and steroid treatment.

RESULTS

Twenty patients, 11 females and 9 males, received a SBT or a SBLT and survived the postoperative period; in the present study we only included 11 children with follow-up periods longer than 1 year. Seven males and 4 females with a mean age of 4.5 years (range, 1 to 20 years) received 6 SBLT and 5 SBT. Nine (82%) were weaned from TPN to an amino-acid or peptide enteral formula during the first 6 months after surgery. During the first year there was a significant increase in total protein from 5.11 +/- 1.8 mg/dl to 6.1 +/- 1.5 mg/dl (p < 0.05) and an increase in albumin from 3.8 +/- 0.9 mg/dl to 4.5 +/- 1.1 mg/dl (p < 0.05). There was an increase in weight Z-score in 9 patients (82%) during the first year. Mean Z-score improved from - 2.6 +/- 1 at transplant to - 1.0 +/- 0.6 (p < 0.05) after 1 year. Three patients (27.2%) had at least one rejection period, which was treated with steroids alone or in combination. Mean weight Z-score 1 year after surgery was - 0.9 +/- 0.6 for patients without rejection and - 1.24 +/- 0.8 for those with at least one rejection episode treated with steroids (p > 0.1). Four patients (36%) had at least one catheter-related sepsis episode. Mean weight Z-score 1 year after surgery was - 1.01 +/- 0.6 for patients without catheter-related sepsis and - 1.24 +/- 0.8 for those with at least one catheter-related sepsis episode (p > 0.1).

CONCLUSIONS

There was a significant improvement in weight Z-score and biochemical nutritional parameters 1 year after receiving a small bowel graft. No influence of steroids or catheter-related sepsis on children's nutritional status was noted 1 year after surgery, although this point will need further evaluation.

[Bronchial and appendiceal carcinoid tumors]

BACKGROUND

Carcinoid tumor (CT) is an unusual neoplasm observed in several locations and associated with the production of vasoactive substances and occasionally with carcinoid syndrome (flushing, diarrhea, wheezing).

PATIENTS AND METHODS

A retrospective review of the medial records of all children with a diagnosis of CT treated in our service between 1966 and 2003 was performed.

RESULTS

Ten patients (5 boys and 5 girls with a mean age of 8 years) were diagnosed with CT. Eight had CT of the appendix, of which 4 showed the typical clinical presentation of acute appendicitis. Seven of these tumors were localized at the tip of the appendix and measured 2 cm or less. In one patient, the tumor was located at the cecum and measured 3.5 cm. In this patient, reoperation with ileocecal resection was performed. Two patients (4 and 6 years old) had bronchial CT associated with chronic respiratory manifestations. An accurate diagnosis was made after a 1-year follow-up. Pneumonectomy and tracheobronchial sleeve resection were carried out. None of the patients showed symptoms of carcinoid syndrome. All the patients underwent biochemical and radiological studies and fiberoptic bronchoscopy during follow-up. All the patients are currently disease-free.

CONCLUSIONS

Typical symptoms of acute appendicitis were not observed in half of patients with CT of the appendix. CT associated with carcinoid syndrome is exceptional in pediatric patients. In most CT of the appendix, simple appendicectomy was associated with an excellent prognosis. Diagnosis of bronchial TC tends to be delayed and consequently CT should be considered in the differential diagnosis of children with respiratory symptoms unresponsive to standard medical treatment.

[Soft tissue sarcomas (1991-2004)]

BACKGROUND

The aim of this study is to review the results of the treatment of soft tissue sarcomas (STS) in our Department during the last 13 years.

MATERIAL AND METHODS

Fifty-seven children (39 rhabdomyosarcomas (RMS) and 18 other types of sarcomas) have been treated. Nineteen RMS were excluded because they were treated by oher departments. The charts of 39 chidren were analysed evaluating several parameters (age, sex, location, histology, initial stage, clinical and surgical treatment and results) as prognostic factors using actuarial survival analyses and log-rank tests.

RESULTS

1. RMS: Median age at diagnosis was 2.3 years (range 6 m-16y). Twelve were genitourinary, 3 thoracic, 3 abdominal, 1 was located in limb and 1 in the neck. Histologically, 13 were embryonal, 5 botryoid, 1 alveolar and 1 fusiform. At diagnosis, 74% were in stages I or II. Fine needle aspiration biopsy (FNAB) was made in 5 children and the result was always imprecise or mistaken. Surgical biopsy was made before the definitive surgery in 12 cases. In the remaining 8 children the diagnosis was made only after surgical resection. With an mean follow-up of 70 +/- 43 moths, 6 children died. The prognostic factors associated with poor outcomes were genitourinary location, non radical excission, the presence of distant metastases at onset and alveolar histology. 2. Other sarcomas: Median age at diagnosis was 10.9 years (range 4 days-15 years). Among this group, there were 6 fibrosarcomas, 4 indifferentiated sarcomas, 3 synovial sarcomas, 2 abdominal desmoplastic small round cell tumours, 2 neurofibrosarcomas and 1 leiomyosarcoma. Only 9 received chemotherapy and one radiotherapy. All but one were operated. Five out ot the 19 died.

CONCLUSIONS

Although the role of surgery is crucial, it is necessary to refine the initial histological diagnosis, because neither the PAAF or the biopsy have always been correct. The negative prognostic factors in our series were metastases present at diagnosis, genitourinary location and alveolar (RMS), desmoplastic or indifferenciated histology.

[Esophageal replacement. 12 years experience]

Esophageal replacement is a surgical procedure rarely indicated in children. It is used in esophageal atresia type I and long-gap atresia when anastomosis is not possible, corrosive strictures and other unusual causes. Type and location of the graft depend on etiology and surgeon preferences. We analyse our results of a large series of esophageal replacement.

METHODS

. We reviewed esophageal replacements carried out in our department between January-1992 and December-2004. We report 29 patients (15 girls and 14 boys) with ages ranging from 2 months until 14 years old (median 24 months). 11 (37.9%) had esophageal atresia type I, 7 (24.1%) long-gap esophageal atresia, 8 (27.5%) caustic esophagitis, 1 herpetic esophagitis, 1 candida esophagitis and 1 esophageal necrosis due to sclerotherapy. Colon was used for substitution in 25 cases (86.2%) and stomach in 4 (13.8%). Graft location was retromediastinal in 25 children (86.2%), retrosternal in 3 and subcutaneous in 1. Native esophagus was removed in all but 2 out of 3 retrosternal cases.

RESULTS

After a follow up between 7 and 145 months (median 76 months) all children have a functional graft. Actually all patients tolerate oral feeding in a satisfactory way, and have had a normal pondostatural growth. Post-operative complications were pyloric obstruction in 3 patients (10.3%), upper anastomosis stricture in 3 (10.3%), 2 (6.9%) surgical wound evisceration, 2 (6.9%) diaphragmatic hernia, 1 (3.4%) retro-mediastinal abscess and 1 (3.4%) colo-gastric emptying difficulties. Also 2 pleural effusions, 1 cervical wound abscess and 1 abdominal wound one. Re-operation was needed in 11 patients (38%) due to these adverse events. Other complications were conservatively solved: 6 (20.7%) salivary fistula, 1 intestinal suboclusion and a dumping syndrome. One girl died due to a mycotic mediastinal abscess with perforation of the aorta 11 days after surgery. Overall survival was 96.5%.

CONCLUSIONS

Esophageal replacement has limited indications. It allow a good functional result, with adequate oral feeding and normal growth. We believe that both colon and stomach have similar outcomes, but gastric pull-up is easier to perform. It is a major surgery whose risk of complications is higher in early post-operative time.

[Congenital portosystemic shunt. The Abernethy malformation]

BACKGROUND

Congenital portosystemic shunt (CEPS) is a rare condition that was first reported by John Abernethy in 1793. Two types of CEPS are described: type I (side to end anastomosis) or congenital absence of the portal vein, and type II (side to side anastomosis) with portal vein supply partially conserved. Type I CEPS is usually seen in girls and associates multiple malformations as polysplenia, malrotation, and cardiac anomalies. Type II is even rarer with no sex preference and no malformations associated. Hepatic encephalopathy is a common complication of both types in adulthood. Liver transplantation is the only effective treatment for symptomatic type I CEPS. A therapeutic approach for type II could be surgical closure of the shunt.

OBJECTIVE

To analyse our experience in diagnosis and management of portosystemic shunts.

METHODS

We report 4 cases of CEPS (3 type I and 1 type II) diagnosed between January-1997 and March-2005 in our department.

RESULTS

We present 4 patients with ages at diagnosis ranging from 0 to 28 months, 3 type I CEPS (2 boys and 1 girl) and 1 boy type II. The type I girl was prenatally diagnosed at 12 weeks of gestation. Initial clinical signs in type 1 boys were splenomegaly and hypersplenism, both with normal pondo-statural growth. No polysplenia or cardiac anomalies were assessed. One of them presented mild developmental delay, dismorphic features and facial telangiectasias. He had normal coagulation tests with chronic hepatic dysfunction (high transaminases) and regenerative nodular lesions were seen by imaging techniques. The other type I patient had hypoprothrombinemia, tendency to capillary bleeding (haematomas and epistaxis) with preserved liver function. Both patients have developed mild portal hypertension and present steatosis signs at liver biopsy. The type I girl presents a 21 trisomy and associates a cardiac anomaly (interauricular communication). Her hepatic function test are normal but liver calcifications can be seen by ultrasound. Type II child associates hypospadias but he has no clinical sigh or symptom related to the shunt. In our three cases diagnosis was suggested by conventional and Doppler ultrasound and confirmed by angio-resonance imaging. All our patients are included in a meticulous clinical and radiological follow-up with no need of surgical treatment for the shunt until now.

CONCLUSIONS

Although diagnosis of these malformations could be casual we have to think about CEPS in children presenting unspecific liver disease. Magnetic angio-resonance imaging is actually the best diagnosis methods for CEPS. These patients have a high risk for developing hepatic encephalopathy and portal hypertension, so a careful follow-up is required although surgery is not usually needed until adulthood.

Teratomas of the neck and mediastinum in children

This retrospective study reviews a series of teratomas of the neck and mediastinum aiming at defining the features of these particular locations. We recorded prenatal diagnosis, perinatal management, clinical and radiologic features, pathology, surgical strategies and results in cervical and mediastinal teratomas treated over the last 10 years. During this period we treated 66 children with teratoma of which 11 (6 male and 5 female) had cervicomediastinal locations. Five babies had cervical teratomas extended into the anterior mediastinum in two cases. Prenatal diagnosis was made in three (two with polyhydramnios). Four babies were born by C-section and only one had a successful EXIT procedure. The diagnosis was confirmed by imaging and increased AFP. Surgical treatment involved total tumor removal and in one case subsequent removal of lymph node metastases. All children survived except one in whom airway could not be cleared at birth. Two children bear mild hypothyroidism. During the same period six patients aged 0-17 years were treated for mediastinal teratoma. Only one was prenatally diagnosed and only two had some dyspnea. Removal was performed either by median sternotomy, thoracotomy, or thoracoscopy. They all survive and are free of disease. Teratomas of the neck may cause fetal disease and unmanageable neonatal airway obstruction. Prenatal diagnosis and planned multidisciplinary management are mandatory at birth. In contrast, only some mediastinal tumors cause respiratory embarrassment. Although benign, these tumors are sometimes immature and may metastasize to regional lymph nodes. Total surgical removal is curative. Thyroid insufficiency may be present at birth in cervical teratomas and may be aggravated by surgery.

[Treatment protocol for extravasation lesions]

INTRODUCTION

Morbidity of tissue extravasations is far of being properly considered in our hospitals. The increased survival rate in very low prematures and severe oncological patients has also produced an increase in the incidence of this complication, that in the most of the cases are not agressively treated in order to minimize the extravasation consequences. We have reviewed our experience in the treatment of these lessions using either injection and saline flushing of the subcutaneous (Gault tissue protocol, 1993) or coverage with artificial dermis in cases with irreversible necrosis.

PATIENTS AND METHODS

Between 1998 and 2004, 15 patients with a median age of 3 years (range 3 months- 12 years) were treated because of extravasation injuries. The extravasated solutions were: parenteral nutrition (7), calcium salts (4) and doxorrubicine (4). Ten patients (66%) were treated inmediately according to the Gault protocol. Seven out of the 10 did not suffer any cutaneous loss, and the remaining 3 had only minimal lessions. Debridement of inviable tissue and coverage with articial dermis after 2 or 3 weeks was made in 5 patients (33%). All of them obtained functional and esthetic satisfactory outcomes.

CONCLUSIONS

Extravasation injuries must be early evaluated by the surgeon and treated inmediately using saline instilation and subcutaneous flushing. In severe cases with total skin necrosis, artificial dermis proporcionates good esthetic and functional results, similar to other complicated techniques, which are nor indicated in prematures or critical oncological patients.

[Results of the treatment of congenital diaphagmatic hernia with conventional terapeutics modalities]

AIM

In this study, we analyze our results in the treatment of congenital diaphragmatic hernia (CDH) using conventional ventilatory therapy without ECMO.

PATIENTS AND METHODS

fifty one CDH patients (27 males and 24 females) treated at our institution between 1997 and 2004 were reviewed. Data referred to obstetrics, prenatal diagnosis, newborn care, type of hernia and surgical treatment were analyzed. We recorded ventilatory treatment modalities and the outcome of the patients. We also compared the survival of our series with those expected using the formula proposed by the CDH study group in 2001. We finally analized separately those patients with early clinical presentation and who fulfilled ECMO criteria. Data from necropsies were also recovered when available.

RESULTS

Prenatal diagnosis was made in 58% of the patients. Fifty nine percent were born by c-section. The diaphragmatic defect was left-sided in 42 patients, right in 8 and bilateral in 1. Ten patients needed a prosthetic patch to close the defect. Eighteen out of the 51 patients (35%) died, 11 of them without surgical treatment. Early presentation of clinical picture was evident in 44 patients; among them 46% required high frequency ventilation and 53% nitric oxide therapy. Medium age at operation was 56+/-49 hours. The 7 children with late clinical presentation are alive. Among the 44 remaining patients, 26 are also alive (59,09%), data similar to those expected by the formula (62.39%, p>0.05). Fifteen patients had oxigenation index (IO) over 40, with a stimated survival rate of 48%, a statistically significant lower rate when compared to patients with IO<40. None of the patients with IO>40 survived; in 4 out of the 7 available necropsy studies, a severe lung hypoplasia was found (index lung weight/body weight <0.006). Among the remaining 27 children with IO<40, 24 (90%) are alive.

CONCLUSIONS

A survival rate over 90% can be achieved by conventional ventilatory measures in patients with IO<40. In our experience, children with IO>40 are rarely candidates to ECMO therapy because of the associated severe lung hypoplasia confirmed by necropsy studies.

[Hirschsprung disease: lessons learned from the last 100 cases]

We analyize our experience in the management of the last consecutive 100 Hirschsprung's disease (HD) patients divided into two periods: 1992-1997 and 1998-2004, in order to find out differences in morbidity, mortality and outcome between them.

MATERIAL AND METHODS

During this period, 72 males and 28 females were treated. Twelve had family history and five suffered from Down's syndrome. Information about clinical onset, need of stomas, surgical procedures, continence, outcome and mortality was recorded. We compared the results between the two groups with non-parametrics stadistics test.

RESULTS

50% of patients were symptomatic in the newborn period and 25% of them needed some surgical procedures. Seventy four patients suffered from rectosigmoid forms, fourteen colic forms and twelve were total colonic HD (7 with small bowel extension). Hystochemistry was diagnostic in 98%. Nursing was effective in 47 cases. Differences in the need of stomas were found between the two periods: 30% during the first period and 6% during the second one (p<0,05). Twenty percent (20) of the patients suffered from enterocolitis (with no differences between both groups), and 13 of them still had enterocolitis episodes in spite of stomas or pull-through procedures. We performed 49 Swenson, 29 Soave, 14 transanal and 2 Lester-Martin procedures. The median age at definitive operation was smaller in the last period when compared to the first (p< 0.05). We found good results on continence in 86%, with no relation with definitive surgical procedure nor with the period of time studied.

CONCLUSIONS

The younger age at definitive treatment, the performance of stomas and the increase of transanal procedures were the principal differences between the two groups.