Marcelo Martinez-Ferro

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis.

Objectives:For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeons success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach. Methods:A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded. Results:In these 104 patients, the mean age at operation was 1.2 days (±1.1), the mean weight was 2.6 kg (±0.5), the mean operative time was 129.9 minutes (±55.5), the mean days of mechanical ventilation were 3.6 (±5.8), and the mean days of total hospitalization were 18.1 (±18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day. Conclusions:The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.

The use of magnets with single-site umbilical laparoscopic surgery

Single-site umbilical incision laparoscopic surgery (SSULS) is increasingly being used to treat a variety of childhood surgical diseases. Existing SSULS approaches have inefficient triangulation and poor ergonomics. In an effort to overcome these shortcomings, magnet-assisted laparoscopy was developed. Specialized magnetic graspers are introduced through a standard 12-mm port and are controlled by a powerful external magnet. This study is a retrospective analysis of all magnet-assisted laparoscopic operations performed at the Fundacion Hospitalaria Private Childrens Hospital from September 2009 to January 2011. Outcomes include demographics, diagnosis, operative time, intraoperative complications, and conversion rates. Forty-four magnet-assisted laparoscopic operations were performed. The operations included 23 appendectomies, 8 cholecystectomies, 3 Nissen fundoplications, 2 gastrojejunostomies, 2 splenectomies, 2 ovarian tumor/cyst resections, 1 retroperitoneal lymphangioma resection, 1 left adrenalectomy, 1 total abdominal colectomy and 1 pulmonary wedge resection. The mean operative times for the most commonly performed operations were 61 minutes for appendectomy and 93 minutes for cholecystectomy. The operations were classified as follows: Group I, adjunct to conventional laparoscopy (5 operations); Group II, adjunct to multiple-access umbilical laparoscopy (11 operations); and Group III, true single-port laparoscopy (28 operations). Among Group II/III operations, 6 operations required 1 additional port outside the umbilicus. No operations required more that 1 additional port, and no operations were converted to the open technique. There were no intraoperative complications. Magnet-assisted laparoscopic surgery is safe and effective in children. The use of magnetic graspers improves triangulation and ergonomics while reducing the number and size of abdominal incisions.

New approaches to pectus and other minimally invasive surgery in Argentina

This is a presentation about the development of pediatric minimally invasive surgery and other pediatric surgical practices in Argentina. For the last 15 years, based on a collaborative approach, many surgical and nonsurgical procedures have been used in the treatment of long gap esophageal atresia and thoracic wall deformities. These procedures are described and detailed in original algorithms that are currently being used to treat our patients.

Extrathoracic esophageal elongation (Kimura's technique): a feasible option for the treatment of patients with complex esophageal atresia

AIM The aim of this study was to evaluate the outcome of all patients who underwent an extrathoracic esophageal elongation (EEE) (Kimuras 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.

Initial Experience with Magnet-Assisted Single Trocar Appendectomy in Children

BACKGROUND Single-incision laparoscopic surgery (SILS) is increasingly being used to treat acute appendicitis. Existing SILS techniques suffer from inefficient triangulation and poor ergonomics. In an effort to improve on existing SILS techniques, we developed the magnet-assisted single trocar (MAST) appendectomy. SUBJECTS AND METHODS We retrospectively analyzed all MAST appendectomies performed between March 2010 and February 2011. Outcomes included demographics, diagnosis, operative time, hospital stay, and complications. RESULTS Twenty-three MAST appendectomies were performed in 10 boys and 13 girls. The mean age at operation was 12.22 years (range, 5-19 years), and the mean weight was 46.5 kg (range, 25-82 kg). At presentation the mean white blood cell count was 15,000 with 74% polymorphonuclear neutrophils. The mean operative time was 61 minutes (range, 20-105 minutes), and length of stay was 3.6 days (range, 1-7 days). In total, 4 operations (17%) required one additional 5-mm trocar to complete the operation, and none was converted to an open operation. There were no intraoperative complications, nor were there any wound infections. CONCLUSIONS MAST appendectomy is safe and effective in children. Magnetic instruments provide excellent triangulation and improve ergonomics. This technique uses a single 12-mm trocar and can be performed without the aid of a surgical assistant.

Changes in chest compression indexes with breathing underestimate surgical candidacy in patients with pectus excavatum: A computed tomography pilot study

BACKGROUND Haller Index (HI) ≥3.25 by computed tomography (CT) at end-inspiration has been used to indicate surgical correction in patients with pectus excavatum. However, chest wall diameters vary with breathing and may modify HI values and surgical indications. The aim of our study was to report the changes in HI with breathing and their impact in the surgical indication rates. METHODS Thirty six patients with pectus excavatum underwent chest CT evaluation at both end-inspiration and end-expiration. HI was derived by dividing the transverse diameter (TD) of the chest by the anteroposterior diameter (APD). Cardiac compression index (CCI) was then calculated by dividing the cardiac TD by the APD. RESULTS Mean patient age was 19 ± 7 years old and 86.8% were males. From end-inspiration to end-expiration, large changes in APD values corresponded to large changes (29.6%) in HI values. CCI increased significantly during end-expiration, primarily driven by an increase on the cardiac TD. Surgical indication was found in 71% and 91% of patients during end-inspiration and end-expiration, respectively (p<0.05). CONCLUSIONS This study showed that the severity indexes of the pectus excavatum were all significantly more severe at end-expiration than at end-inspiration, leading to an increase in surgical candidacy. We therefore recommend performing the CT at end-expiration.

Laparoscopic Treatment of Postnecrotizing Enterocolitis Colonic Strictures

The current report is a multicenter study of a series of infants who developed colonic strictures (CS) as a sequelae of necrotizing enterocolitis (NEC) and who were treated successfully with laparoscopic intestinal resection and primary anastomosis. During 2005-2008, 11 neonates (gestational ages, 32-38 weeks), with a mean birth weight of 1.7 kg (range, 0.96-2.2) and a mean weight at operation of 3.04 kg (range, 1.6-4.4 were approached laparoscopically, following the diagnosis of a post-NEC-CS. The two surgical techniques were: 1) laparoscopic mobilization with extracorporeal resection and anastomosis (LERA) in 4 (36%) and 2) laparoscopic mobilization with intracorporeal resection and anastomosis (LIRA) in 7 (64%) patients. Laparoscopy was effectively performed in all cases without conversion to open surgery. The median operative time was 93 minutes (range, 80-121). The anastomosis was colocolic in all patients, except in 1 case, in which it was colorectal. There were no operative complications. All babies recovered uneventfully and started oral feeding at a median time of 3.5 days (range, 1-11) postoperatively. Hospital discharge was at a median time of 9 days (range, 2-29) following operation. No recurrent strictures have developed.

Thoracoscopic Repair of Esophageal Atresia with Fistula: Initial Experience

We present the first nine neonates with esophageal atresia and distal tracheoesophageal fistula (TEF) treated by the authors with a primary thoracoscopic repair. To close the fistula and create the esophageal anastomosis, a three-trocar approach with carbon dioxide insufflation is required. Primary correction was accomplished in all cases. No operative complications were encountered. The mean operative time was 105 minutes (range, 70-189 minutes). Three patients (33%) developed anastomotic stricture that required periodic balloon dilation; results were good. Two patients (22%) developed anastomotic leak; one case was mild and secondary to gastric perforation. The cosmetic results were significantly better than those observed after open thoracotomy. Although thoracoscopic primary repair of TEF appears to offer considerable advantages, further experience and a larger number of cases are required to advance the learning curve; thus, at this stage, the rates of stricture and leakage seem to be higher than tho...

International innovations in pediatric minimally invasive surgery: the Argentine experience

This is a presentation about innovations in pediatric minimally invasive surgery and a review of the Argentine experience. The most representative are (1) the thoracoscopic treatment of long gap esophageal atresia with novel techniques; (2) the nonsurgical and minimally invasive treatment of chest wall deformities, particularly of pectus carinatum; and (3) the use of magnetic surgical devices in classic laparoscopy and transumbilical surgery.

Exaggerated Interventricular Dependence Among Patients With Pectus Excavatum: Combined Assessment With Cardiac MRI and Chest CT

OBJECTIVE We sought to explore whether patients with pectus excavatum have exaggerated interventricular dependence and to evaluate the impact of the malformation severity (assessed on CT) on both anatomic and functional cardiac parameters (assessed on cardiac MRI). SUBJECTS AND METHODS The current study involved consecutive patients with a diagnosis of pectus excavatum who were referred to undergo cardiac MRI and chest CT to establish surgical candidacy or to define treatment strategies. RESULTS Sixty-two patients with pectus excavatum underwent cardiac MRI and chest CT. Fifty (81%) patients were male, and the median age was 17.5 years (range, 14.0-23.0 years). Forty-seven (76%) patients had evidence of right ventricular compression. The left ventricle showed a significantly decreased end-diastolic volume (inspiration vs expiration: 70.4 ± 11.6 vs 76.1 ± 13.7 mL/m2, respectively; p = 0.01) and a significantly higher eccentricity index (1.52 ± 0.2 vs 1.20 ± 0.1, p < 0.0001) during inspiration than during expiration. The median respiratory-related septal excursion was 8.1% (interquartile range, 5.1-11.7%). Patients with pericardial effusion showed a significantly higher pectus excavatum severity index than patients without pericardial effusion (6.3 ± 3.4 vs 4.4 ± 1.3, respectively; p = 0.003). Patients with a relative septal excursion equal to or larger than 11.8% showed a significantly higher pectus excavatum severity index than patients with a relative septal excursion of less than 11.8% (6.3 ± 2.6 vs 4.7 ± 2.4, respectively; p = 0.05). CONCLUSION In this study, patients with pectus excavatum showed significant alterations of cardiac morphology and function that were related to the deformation severity and that manifest as an exaggerated interventricular dependence.