Digital Thoracic Drainage System: A New Tool For Pediatric Thoracic Surgery.

INTRODUCTION: Digital thoracic drainage systems usage in pediatrics is underreported, making current recommen- dations based on those for adults. We aim to review our experience on the use of this digital system and to evaluate the adequacy of those recommendations. METHODS: Retrospective analysis of patients in whom digital thoracic drainage system was used. All patients were submitted to thoracoscopic bleb/apical lung resection for primary spontaneous pneumothorax. Initially patients were man- aged using the few existing recommendations for children, but after 2 unsuccessful cases we changed our approach into tube clamping after continuous air leak < 5mL/min for at least 24 hours. RESULTS: Seventeen procedures (median 17.2-years) were performed; there were no intraoperative complications. After changing the air leak target, 11 procedures were consecutively managed without complications; the median number of chest radiographs per procedure was 3.0 and the median number of days with chest tube was 4.0 days. CONCLUSIONS: This is the first report on the usage of this system in children in Portugal. This system constitutes an important technological innovation, but it needs more data gathering and prospective trials in order to maximize its use in children. The authors suggest an algorithm for the management of thoracic digital drainage in children: removal of chest tubes when the air leak is <5mL/min for 24 hours and to perform chest tube clamping for a minimum of 6 hours before removal.

Thoracic Outlet Syndrome after Minimally Invasive Repair of Pectus Excavatum in a 15-Year-Old Boy: A Case Report.

Nuss procedure has become the treatment of choice in pectus excavatum mainly because of the excellent functional and cosmetic results. Despite the good results, several complications have been reported. The aim of this study is to describe a case of thoracic outlet syndrome (TOS) after Nuss procedure and review the management of such rare complication. A 15-year-old boy otherwise healthy was submitted to Nuss procedure, with no perioperative complications. Two-weeks later, the patient complained of right-hand paresthesia, progressive weakness of the right arm and coldness. After imaging and electromyography, TOS diagnosis was established. Removal of the bar was proposed but refused by the patient. Conservative management with rehabilitation exercising and nerve nourishing was initiated. At 7 months, the patient recovered arm and hand function. Abrupt structural changes of thoracic cavity with marked elevation of the upper chest induce nerve and vascular compression arousing a TOS and should be acknowledged as one potential complication of Nuss procedure. Conservative management can be an alternative treatment to bar removal, showing good results on functional recovery in early stages of compression.

Thoracoscopic sympathotomy for palmar hyperhidrosis: How young is too young?

BACKGROUND/PURPOSE: Primary hyperhidrosis affects 1%-3% of the general population, with increased incidence in teenagers, having an important impact in the quality of life. This study evaluates the efficacy and patients' satisfaction after bilateral thoracoscopic sympathotomy. METHODS: Retrospective analysis of pediatric patients with palmar primary hyperhidrosis that underwent bilateral thoracoscopic sympathotomy over the last eight years. The procedure was performed with 2 ports and simple transection of the sympathetic chain. Pre and postoperative sweating severity was evaluated by telephone interview, using the Hyperhidrosis Disease Severity Scale (HDSS). RESULTS: 23 patients (19 girls; 15.5 [11-19] years-old) underwent bilateral thoracoscopic sympathotomy. All complained of palmar hyperhidrosis, which resolved in all cases. Compensatory sweating occurred in 47.8% of patients. 21 patients answered the telephone interview: all of them would recommend the surgery to others. Sweating severity improved in all patients, with a mean decrease of 1.95 values of the HDSS from preoperative to postoperative evaluation (p < 0.05). There was neither morbidity nor mortality. CONCLUSIONS: Bilateral thoracoscopic sympathotomy is a safe and effective treatment for primary palmar hyperhidrosis. Being the first report on pediatric application of HDSS, we conclude that children are very satisfied with the final outcome. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Biliary Atresia - Clinical Series.

INTRODUCTION: Biliary atresia is the main cause of death by hepatic failure and the main indication for liver transplant in children. This study aims to analyze the population with this diagnosis, treated between 2000 and 2015 at Hospital de São João. MATERIAL AND METHODS: Descriptive, observational, and retrospective study, including the patients with biliary atresia, diagnosed and treated between January 1, 2000 and December 31, 2015. We analyzed epidemiologic, clinical, biochemical, and image data, as well as registered complications and present status. RESULTS: Eighteen patients were evaluated. The median age at time of Kasai portoenterostomy was 63 days of life, with better prognosis for those patients who had surgery before 72 days. The procedure was successful in 2/3 of cases. There was a significant association between recurrent cholangitis and survival. Five cases of transplant and 2 deaths, one of them after transplant, were registered. Survival with native liver was 77.8%, 72.2%, and 64.2% at 1, 5, and 10 years of follow-up, respectively. DISCUSSION: The presentation and evolution of patients was similar to other studies. However, there was a higher surgical success and survival rates at 5 and 10 years of follow-up than most series. Age at surgery and recurrence of cholangitis were the only factors significantly related to prognosis. CONCLUSION: In spite of the low number of patients (1,125/year), our results were similar to those of other reference centers.

INTRODUÇÃO: A atresia das vias biliares representa a principal causa de morte por insuficiência hepática e a principal indicação para transplante hepático em idade pediátrica. O objetivo deste estudo é analisar a população com este diagnóstico, tratada entre 2000 e 2015 no Hospital de São João. MATERIAL E MÉTODOS: Estudo descritivo, observacional e retrospetivo, incluindo-se doentes com atresia das vias biliares diagnosticados e tratados entre 1 de Janeiro de 2000 e 31 de Dezembro de 2015. Foram analisados dados epidemiológicos, clínicos, bioquímicos, imagiológicos, idade à data da cirurgia, complicações ocorridas e o estado atual. RESULTADOS: Foram avaliados 18 doentes. A idade mediana à data da portoenterostomia de Kasai foi de 63 dias de vida, verificando-se um melhor prognóstico nos pacientes operados antes dos 72 dias. Foi constatada drenagem biliar adequada em 2/3 dos casos aos 6 meses. Verificou-se uma associação significativa entre a ocorrência de episódios recorrentes de colangite e a sobrevida. Registaram-se 5 transplantes e 2 óbitos, um dos quais pós-transplante. A sobrevida com fígado nativo foi de 77.8%, 72.2% e 64.2% ao 1º, 5º e 10º anos de seguimento, respetivamente. DISCUSSÃO: A apresentação e evolução dos pacientes coincidiu, de um modo geral, com o descrito na literatura. No entanto, constatou-se uma taxa de sucesso operatório e de sobrevida com fígado nativo aos 5 e 10 anos superiores à maioria das séries. A idade à data de cirurgia e a recorrência dos episódios de colangite foram os únicos fatores que se mostraram significativamente relacionados com o prognóstico. CONCLUSÃO: Apesar do número reduzido de doentes (1,125/ano), foram registados resultados comparáveis a outros centros de referência.

Trans-umbilical laparoscopic-assisted appendectomy in the pediatric population: comparing single-incision and 2-trocar techniques.

INTRODUCTION: Trans-umbilical laparoscopic-assisted appendectomy (TULAA) combines advantages of open surgery with benefits of laparoscopy and can be performed either by single-incision or with two trocars; the present study aims to compare outcomes and cost of these techniques in a pediatric serie. MATERIAL AND METHODS: Patients undergoing TULAA between July 2013 and June 2014 were retrospectively reviewed. There were two groups: A (single-incision) - one umbilical trocar for a telescope with inbuilt working channel; and B (2-trocar) - one umbilical trocar for a 'standard' telescope plus a supra-pubic trocar for instruments. RESULTS: One-hundred and eighty-nine patients (112 males, age: 12[2-17] years) underwent TULAA; 32(17%) presented with perforated appendicitis. Group A encompassed 157 and group B 32 patients; age, gender, proportion of perforated appendicitis, and follow-up were similar. Operative time was 46 [21-145] min in group A, and 54.5[30-111] in group B (A vs B, p = 0.087). Length of hospital stay was 2 [1;22] days in group B, and 2 [0;24] in group A (A vs B, p = 0.136). The prevalence of post-operative complications was similar: 11 (7%) cases in group A and 2 (6.3%) intra-abdominal abscesses in group B. Using disposable trocars, the more expensive starting point of single-incision technique may be reversed after 27 procedures. CONCLUSION: Single-incision and 2-trocar TULAA are effective techniques with low complication rates and similar outcomes. Despite being technically more demanding, single incision may be advantageous because there are no visible scars, and potentially cheaper in hospitals where disposable trocars are used.