Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter.

Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

Peri-Kasai portoenterostomy sutures anchoring the jejunal loop to Glisson capsule: A novel modification to reduce the incidence of cholangitis.

BACKGROUND: Kasai portoenterostomy (KPE) is the standard surgical management for biliary atresia (BA). To improve the outcome these infants were operated on within the first two months of life. The success of the procedure is reflected by clearance of jaundice and either absence or occurrence of fewer attacks of cholangitis. The failure of the procedure indicates liver transplantation (LT). OBJECTIVE: to reduce the incidence of the recurrent attacks of cholangitis by peri-KPE sutures anchoring the jejunal loop to the Glisson capsule. METHODS: It is a retrospective study that included 45 infants diagnosed with BA and who were operated on at an age younger than 60 days. They were categorized into two groups, Group A (n = 23) included infants treated with the classic KPE, and Group B (n = 22) included infants treated in the same way plus peri KPE sutures anchoring the jejunal loop to the Glisson capsule. RESULTS: The mean operative time in Group A was 149.3 min versus 164.8 min in Group B (p-value 0.039). The mean level of bilirubin was 2.2 versus 2.1 in Group A and Group B respectively at two years follow up. The total attacks of cholangitis per patient were significantly lower in Group B than in Group A (cutoff value = 3), which was reflected by the significant reduction of the incidence of LT in Group B. CONCLUSION: peri KPE sutures anchoring the jejunal loop to the Glisson capsule significantly reduced the incidence of recurrent attacks of cholangitis and subsequently decreased the requirement of LT on the short-term follow-up.

Treatment of Gynecomastia by Endoscopic Subcutaneous Mastectomy in Adolescents.

Background: Morbidity of traditional open surgery for the treatment of gynecomastia includes asymmetry, retraction of the nipple, and poor scarring. Other approaches were described to improve the results. Endoscopic subcutaneous mastectomy (ESCM) was reported in adult series, including a few adolescents. This technique was considered as safe with good aesthetic results. The aim of this study was to evaluate the results of ESCM in an adolescent series. Patient and Methods: We treated 19 adolescents with Simon's grade IIB and III gynecomastia between June 2014 and July 2018. They could choose open surgery through the nipple or endoscopic surgery by axillary approach. To perform ESCM, three trocars were placed on the midaxillary line to dissect the gland. The resection was performed leaving 1 cm thickness of gland behind the nipple. The gland was extracted after morcellation through the 10 mm trocar. A drainage tube was placed in the cavity. The patients wore a thoracic belt smoothly compressing the operative areas for 15 days. The result was considered as good when there was no remaining gland, good symmetry, and no nipple retraction or nipple lateral displacement. Results: During the study period, 12 adolescents were treated by ESCM and 7 preferred open surgery. Among the 12 ESCM patients, 7 had bilateral and 5 unilateral gynecomastia. A subcutaneous injection of serum was done in the last 6 patients to facilitate the creation of the work space. A 2- or 3-mm second-degree burn occurred in 4 cases, 2 on the nipple and 2 just above the nipple, with a 2 mm remaining scar above the nipple in 1 case. The postoperative course was uneventful in 11 adolescents. One subcutaneous seroma expanded at 15 days postoperative and resolved after 3 weeks of prolonged compression by thoracic belt. The adolescents had 11 good results and 1 persistent asymmetry; 2 other asymmetries had a spontaneous improvement after 1 or 2 years. Conclusion: ESCM is feasible and safe for the treatment of gynecomastia in adolescents. This technique is challenging but permits to reach good aesthetic results and avoids scars on the anterior wall of the thorax.