José Luis Carvalho

Transvesical thoracoscopy: A natural orifice translumenal endoscopic approach for thoracic surgery

BackgroundRecently there has been an increasing enthusiasm for using natural orifices translumenal endoscopic surgery (NOTES) to perform scarless abdominal procedures. We have previously reported the feasibility and safety of the transvesical endoscopic peritoneoscopy in a long-term survival porcine model as useful for those purposes. Herein, we report our successful experience performing transvesical and transdiaphragmatic endoscopic approach to the thoracic cavity in a long-term survival study in a porcine model.MethodsTransvesical and transdiaphragmatic endoscopic thoracoscopy was performed in six anesthetized female pigs. A 5 mm transvesical port was created on the bladder wall and an ureteroscope was advanced into the peritoneal cavity. After diaphragm inspection, we introduced through the left diaphragmatic dome a ureteroscope into the left thoracic cavity. In all animals, we performed thoracoscopy as well as peripheral lung biopsy. Animals were sacrificed by day 15 postoperatively.ResultsWe easily introduced a 9.8 Fr ureteroscope into the thoracic cavity that allowed us to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. Postmortem examination revealed complete healing of vesical and diaphragmatic holes, whereas no signs of infection or adhesions were observed in the peritoneal or thoracic cavities.ConclusionThis study demonstrates the feasibility of transvesical thoracoscopy in porcine model. However, although this study extends the potential applications of NOTES to the thoracic cavity, new instruments and further work are needed to provide evidence that this could be translated to humans and with advantages for patients.

Delayed gastric emptying and gastroesophageal reflux: a pathophysiologic relationship.

Background Delayed gastric emptying (DGE) is frequent in patients with gastroesophageal reflux (GER), but its pathophysiologic role has not yet been established. To identify a relationship between DGE and GER, we assessed whether DGE increases esophageal acid exposure and the related importance of possible mechanisms. Methods Thirty pediatric patients with pathological GER were divided according to gastric emptying scintigraphy into a DGE group (n = 14) and normal-emptying group (n = 16). The esophageal pH-monitoring parameters of the two groups were compared with respect to the individual variation between postprandial and fasting periods. Results Patients with DGE had less total acid exposure than did those with normal emptying, but patients in both groups had a pathological fraction of time when pH was below 4 in both the postprandial (median: 18 vs. 27.6;P = 0.49) and fasting (8.5 vs. 23.9;P = 0.01) periods. Patients in the normal-emptying group had similar fraction of time when pH was below 4 in the postprandial and fasting periods. However, patients in the group with DGE had a fraction of time when pH was below 4 in the postprandial period that was almost double that presented in fasting period (postprandial to fasting ratio: 2.11:0.90;P = 0.002). The postprandial to fasting ratio for episodes per hour was similar in the two groups (1.81 vs. 1.79;P = 0.62). Patients with DGE had a significantly higher frequency of long episodes in the postprandial period than did those with normal emptying (62.5% vs. 38.2%;P = 0.04). The occurrence of the longest episode in the postprandial period was also significantly higher for patients with DGE (57.1% vs. 6.2%;P = 0.003). Conclusions DGE seems to accentuate postprandial reflux by increasing the volume of refluxate per episode of reflux through an underlying incompetent lower esophageal sphincter.

Endoscopic Closure of Transmural Bladder Wall Perforations

BACKGROUND Traditionally, intraperitoneal bladder perforations caused by trauma or iatrogenic interventions have been treated by open or laparoscopic surgery. Additionally, transvesical access to the peritoneal cavity has been reported to be feasible and useful for natural orifice translumenal endoscopic surgery (NOTES) but would be enhanced by a reliable method of closing the vesicotomy. OBJECTIVE To assess the feasibility and safety of an endoscopic closure method for vesical perforations using a flexible, small-diameter endoscopic suturing kit in a survival porcine model. DESIGN, SETTING, AND PARTICIPANTS This pilot study was performed at the University of Minho, Braga, Portugal, using six anesthetized female pigs. INTERVENTIONS Closure of a full-thickness longitudinal incision in the bladder dome (up to 10 mm in four animals and up to 20 mm in two animals) with the endoscopic suturing kit using one to three absorbable stitches. MEASUREMENTS The acute quality of sealing was immediately tested by distending the bladder with methylene-blue dye under laparoscopic control (in two animals). Without a bladder catheter, the animals were monitored daily for 2 wk, and a necropsy examination was performed to check for the signs of peritonitis, wound dehiscence, and quality of healing. RESULTS AND LIMITATIONS Endoscopic closure of bladder perforation was carried out easily and quickly in all animals. The laparoscopic view revealed no acute leak of methylene-blue dye after distension of the bladder. After recovery from anaesthesia, the pigs began to void normally, and no adverse event occurred. Postmortem examination revealed complete healing of vesical incision with no signs of infection or adhesions in the peritoneal cavity. No limitations have yet been studied clinically. CONCLUSIONS This study demonstrates the feasibility and the safety of endoscopic closure of vesical perforations with an endoscopic suturing kit in a survival porcine model. This study provides support for further studies using endoscopic closure of the bladder which may lead to a new era in management of bladder rupture and adoption of the transvesical port in NOTES procedures.

Gastric inflammatory myofibroblastic proliferation in children

Abstract Gastric inflammatory myofibroblastic proliferation (IMP) is an extremely rare entity in children, which to our knowledge has only been mentioned in case reports. We describe the ninth pediatric case and review the literature concerning the etiology, clinical and laboratory features, pathology, treatment, and outcome. There has been a predominance in preschool females. Abdominal pain, upper gastrointestinal hemorrhage, and an abdominal mass, either isolated or associated, have been the main clinical features. Iron-deficiency anemia has been a constant finding. Lesions are elevated and involve the full thickness of the gastric wall, usually with ulceration of the luminal surface; extragastric extension suggesting malignancy is frequent. Diagnosis is made by histology after surgical excision. There was no mortality directly related to gastric IMP, and only one case recurred after surgical excision. The pathogenesis is controversial, but the finding of Helicobacter pylori in our case may indicate an inflammatory origin. Awareness of this benign lesion and its mimicry of malignancy is important so that inappropriately aggressive therapy can be avoided.

Acute gastric volvulus secondary to a Morgagni hernia

Abstract Gastric volvulus (GV) is a rare surgical emergency in infancy and childhood. The first case of a child with an acute GV secondary to a Morgagni hernia (MH) is reported. The authors briefly discuss the etiology, clinical features, and management of acute GV and review the scattered reports of strangulated MHs in children.

Idiopathic perforation of the gallbladder: A novel differential diagnosis of acute abdomen

A six-year-old boy was referred with suspicion of acute appendicitis. He complained of vomiting and abdominal pain for the last 24 hours. Axillary temperature was 38oC and the abdomen was painful and tender. Complete blood count revealed leukocytosis. Abdominal ultrasonography demonstrated moderate free intraperitoneal fluid, mainly in the right iliac fossa and pelvis. An emergency laparotomy was performed with the presumptive diagnosis of peritonitis secondary to appendicitis but there was a 500 ml bile-stained ascites. Exploration of the abdominal cavity revealed a type I (3) oval perforation (2 cm) of the gallbladder infundibulum (Fig. 1). There were no gallstones or bile duct dilatation. Cholecystectomy was then performed and the child experienced an uneventful recovery. Histological examination did not reveal inflammatory infiltrate or any other significant alteration of the gallbladder wall. The cultures of peritoneal fluid were negative. Postoperative biliary MRI was normal. At 15-month follow-up the child continued to be well. DISCUSSION

Laparoscopic colonic mapping of dysganglionosis.

Abstract Retention of a proximal aganglionic segment or the unrecognized coexistence of other dysganglionoses may jeopardize the definitive surgical treatment of Hirschsprungs disease (HD). To assess the extent of the disease and/or the presence of other dysganglionoses without an additional laparotomy, we developed a laparoscopic-assisted technique to perform colonic full-thickness biopsies. After creation of a pneumoperitoneum, a 5-mm laparoscope is inserted in the supraumbilical area and a working 10/12-mm port is placed in the left iliac fossa. The sigmoid/descending colon is grasped and pulled through the abdominal wall and a full-thickness biopsy done. The same procedure is applied to the transverse and ascending colon. Rectal and colonic biopsy specimens were studied using enzyme histochemical methods. Over the last year, five children aged 7 months to 12 years with dysganglionosis underwent laparoscopic-assisted mapping of the colon. Previous rectal suction biopsies were diagnostic of HD in three patients and suspicious of hypoganglionosis in two. Proximal full-thickness biopsies revealed: normal colon in two cases of HD; coexistent type B intestinal neuronal dysplasia up to the descending colon in the other case of HD; and hypoganglionosis up to the ascending colon in the two patients with suspected hypoganglionosis. The procedures were performed easily, the patients being discharged after 36 to 48 h with no complications. Four children have already undergone pull-through procedures with resection of the affected colon in adhesion-free abdominal cavities and did not develop constipation or enterocolitis. Laparoscopic-assisted mapping of the entire colon is a simple, safe, and effective procedure that may contribute to improving the outcome of intestinal dysganglionosis by better characterization of the disease.

Ectopic pancreas and foveolar hyperplasia in a newborn: a unifying etiopathogenesis for gastric outlet obstruction.

Gastric outlet obstruction in infants usually is attributable to infantile hypertrophic pyloric stenosis (IHPS). Rare causes, such as foveolar hyperplasia (FH) (1–3) or ectopic pancreas (4,5), have been reported. In this case we describe a newborn infant with gastric outlet obstruction related to coexisting ectopic pancreas and FH who was being treated with prostaglandin (PG) E1. A unifying etiopathogenesis for gastric outlet obstruction is proposed.

Duhamel pull-through assisted by transrectal port: a hybrid natural orifice transluminal endoscopic surgery approach

One of the latest surgical innovations is natural orifice transluminal endoscopic surgery (NOTES). We hypothesize that the principles of NOTES could be applied to the laparoscopic Duhamel procedure. Between March 2008 and May 2010, 3 children underwent the laparoscopic Duhamel procedure assisted by transrectal NOTES. Three 5-mm transabdominal trocars were combined with a 12-mm transrectal trocar. We were able to safely apply the principles of NOTES, improving the performance of laparoscopic Duhamel pull-through using current instruments and technology. This new approach avoids the need of an extra transabdominal 12-mm trocar for the endoscopic stapler, allows an easier creation of a smaller rectal stump, and offers the possibility of an extra working port. This hybrid concept can be seen as a transition into the emerging field of NOTES in colorectal surgery.

Intestinal duplication presenting as spontaneous hemoperitoneum.

Intestinal duplications are rare anomalies usually ap-pearing during the first year of life (1–4). Although ul-trasonography, computed tomographic (CT) scans, andscintigraphy may be helpful in diagnosis, intestinal du-plications are often unexpectedly found during laparot-omy (1–4). The blood supply and the muscular coat ofthe intestinal duplication are commonly shared by theadjacent bowel, which usually precludes selective surgi-cal excision (2–5).A case of a new clinical presentation of intestinal du-plication is described.