Reasons for conversions in thoracoscopic repairs of neonatal congenital diaphragmatic hernias: a systematic review.

PURPOSE: This systematic review focused on reasons for conversions in neonates undergoing thoracoscopic congenital diaphragmatic hernia (CDH) repair. METHODS: Systematic search of Medline/Pubmed and Embase was performed for English, Spanish and Portuguese reports, according to PRISMA guidelines. RESULTS: Of the 153 articles identified (2003-2023), 28 met the inclusion criteria and offered 698 neonates for analysis. Mean birth weight and gestational age were 3109 g and 38.3 weeks, respectively, and neonates were operated at a mean age of 6.12 days. There were 278 males (61.50%; 278/452) and 174 females (38.50%; 174/452). The reasons for the 137 conversions (19.63%) were: (a) defect size (n = 22), (b) need for patch (n = 21); (c) difficulty in reducing organs (n = 14), (d) ventilation issues (n = 10), (e) bleeding, organ injury, cardiovascular instability (n = 3 each), (f) bowel ischemia and defect position (n = 2 each), hepatopulmonary fusion (n = 1), and (g) reason was not specified for n = 56 neonates (40.8%). The repair was primary in 322 neonates (63.1%; 322/510) and patch was used in 188 neonates (36.86%; 188/510). There were 80 recurrences (12.16%; 80/658) and 14 deaths (2.48%; 14/565). Mean LOS and follow-up were 20.17 days and 19.28 months, respectively. CONCLUSIONS: Neonatal thoracoscopic repair for CDH is associated with conversion in 20% of cases. Based on available data, defect size and patch repairs have been identified as the predominant reasons, followed by technical difficulties to reduce the herniated organs and ventilation related issues. However, data specifically relating to conversion is poorly documented in a high number of reports (40%). Accurate data reporting in future will be important to better estimate and quantify reasons for conversions in neonatal thoracoscopy for CDH.

Focus of Pediatric Surgical Reports During the SARS-CoV-2 Pandemic: A Narrative Review.

Background: Coronavirus disease-2019 (COVID-19) pandemic impacted surgical activity at health-care facilities and led to significant changes in the characteristics of publications in medical journals. This is a narrative review that outlines the focus of pediatric surgical reports during the ongoing COVID-19 pandemic. Methods: Publications on pediatric surgery during the pandemic were carefully reviewed, and data emerging from reports on COVID-19 were selected to address: (1) the impact of COVID-19 on pediatric surgical procedures; (2) children undergoing surgical intervention; and (3) expansion of telemedicine. Results: Regarding surgical activity in tertiary hospitals, there was a reduction in the number of elective surgeries, with reports of an increase in complicated appendicitis and in testicular torsions with symptoms for more than 6 h. The pandemic impacted specific surgical fields, with reports on trauma, appendectomies, urology, cardiac surgery, and kidney transplant. In children positive for COVID-19 that underwent surgery, postoperative complications were more indicative of the primary surgical pathology and there were no postoperative deaths. In a report of universal screening, <1% of children had positive reverse transcription-polymerase chain reaction (RT-PCR). In a report addressing telemedicine during the pandemic, it was well evaluated by both pediatric surgeons and patients' families, but most surgical departments did not provide the service. Conclusions: The pandemic brought significant changes in surgical care. As expected, there was a reduction in elective surgeries, RT-PCR-positive children did not present worse postoperative outcomes than negative ones but there is still a paucity of data regarding COVID-19 children, and telemedicine may play an important role in health care, especially in times of social distancing.

State of the art in translating experimental myelomeningocele research to the bedside.

Myelomeningocele (MMC), the commonest type of spina bifida (SB), occurs due to abnormal development of the neural tube and manifest as failure of the complete fusion of posterior arches of the spinal column, leading to dysplastic growth of the spinal cord and meninges. It is associated with several degrees of motor and sensory deficits below the level of the lesion, as well as skeletal deformities, bladder and bowel incontinence, and sexual dysfunction. These children might develop varying degrees of neuropsychomotor delay, partly due to the severity of the injuries that affect the nervous system before birth, partly due to the related cerebral malformations (notably hydrocephalus-which may also lead to an increase in intracranial pressure-and Chiari II deformity). Traditionally, MMC was repaired surgically just after birth; however, intrauterine correction of MMC has been shown to have several potential benefits, including better sensorimotor outcomes (since exposure to amniotic fluid and its consequent deleterious effects is shortened) and reduced rates of hydrocephalus, among others. Fetal surgery for myelomeningocele, nevertheless, would not have been made possible without the development of experimental models of this pathological condition. Hence, the aim of the current article is to provide an overview of the animal models of MMC that were used over the years and describe how this knowledge has been translated into the fetal treatment of MMC in humans.

Congenital diaphragmatic hernia repair analysis in relation to postoperative abdominal compartment syndrome and delayed abdominal closure.

AIM: Limited abdominal space in congenital diaphragmatic hernia (CDH) might result in abdominal compartment syndrome (ACS) and require delayed abdominal closure (DAC). This study reviewed outcomes in pediatric ACS/DAC after CDH repair. METHODS: Medline/PubMed, Scopus, Web of Science, Ovid and Lilacs databases were reviewed. Data from studies published in English/Spanish/Portuguese between 1990-2020 was collected. Results are presented as descriptive statistics. RESULTS: Sixteen reports offered 118 children, 112 (94.9%) being neonates. There were six ACS (5.1%) and 112 DAC (94.9%). Regarding ACS, the diagnosis was made clinically (n = 4; 66.7%), using Doppler scans (n = 1; 16.7%) or bladder pressure measurement (n = 1; 16.7%). There was one (16.7%) lethal outcome. The rationale to perform DAC was not clearly stated, and measurement of abdominal pressure was not mentioned in all reports. Silo was the preferred approach in 36 children (32.1%), followed by skin closure only (n = 16; 14.3%), vacuum (n = 10; 8.9%), fascia patch and skin closure (n = 5; 4.5%), fascia patch and vacuum dressing (n = 1; 0.9%), fasciotomy (n = 1; 0.9%); with no DAC technique reported in 43 patients (38.4%). Complications after DAC were reported in nine children (8.1%). One DAC using vacuum dressing that was clinically diagnosed with ACS required silo placement. There were 19 (17%) lethal outcomes. CONCLUSIONS: ACS/DAC after CDH repair are reported more frequently in neonates (112/118; 94.9%). There is no clear rationale stated behind the decision to perform DAC, with the silo being the preferred approach. Criteria need to be worked for DAC in CDH with large herniated content and small volume abdomen to prevent ACS.

Does Biliodigestive Anastomosis Have Any Effect on the Reversal of Hepatopulmonary Syndrome in a Biliary Cirrhosis Experimental Model?

BACKGROUND: Biliary cirrhosis is associated with hepatopulmonary syndrome (HPS), which is related to increased posttransplant morbidity and mortality. AIMS: This study aims to analyze the pathophysiology of biliary cirrhosis and the onset of HPS. METHODS: Twenty-one-day-old Wistar rats were subjected to common bile duct ligation and were allocated to two groups: group A (killed 2, 3, 4, 5, or 6 weeks after biliary obstruction) and group B (subjected to biliodigestive anastomosis 2, 3, 4, 5, or 6 weeks after the first procedure and killed 3 weeks later). At the killing, arterial blood was collected for the analyses, and samples from the liver and lungs were collected for histologic and molecular analyses. The gasometric parameters as well as the expression levels of ET-1, eNOS, and NOS genes in the lung tissue were evaluated. RESULTS: From a total of 42 blood samples, 15 showed hypoxemia (pO2 < 85 mmHg) and 17 showed an increased oxygen gradient [p (A-a) O2 > 18 mmHg]. The liver histology revealed increased ductular proliferation after common bile duct ligation, and reconstruction of bile flow promoted decreased ductular proliferation 5 and 6 weeks post-common bile duct ligation. Pulmonary alterations consisted of decreased parenchymal airspace and increased medial wall thickness. Biliary desobstruction promoted transitory improvements 5 weeks after biliary obstruction (increased parenchymal airspace and decreased MWT-p = 0.003 and p = 0.004, respectively) as well as increased endothelin expression levels (p = 0.009). CONCLUSIONS: The present model showed lung tissue alterations promoted by biliary obstruction. The biliodigestive anastomosis had no clear direct effects on these alterations.

Management and outcomes of gastric volvulus in children: a systematic review.

BACKGROUND: Gastric volvulus (GV) in children is a rare condition. This study reviewed management and outcomes of GV in the pediatric population. METHODS: MEDLINE/PubMed, Embase, and Google Scholar databases were searched for studies in English regarding GV in patients < 18 years old between 2008 and 2017, selected by two reviewers. Results were presented as percentages and medians. Fisher's exact test was used to evaluate categorical variables, and Bonferroni correction was applied for multiple comparisons. RESULTS: Ninety-seven papers with 125 patients were included. The median age was 24 months, with slightly female preponderance. Vomiting was the most common symptom and acute presentation occurred in the majority of cases. History of previous surgery/abdominal trauma was described in 12 and 3 children, respectively. Radiology was diagnostic for GV in most cases. The initial management was surgical in the majority of cases, with most of them including gastropexy, gastrostomy, or gastric resection. Mesenteroaxial GV was associated with acute presentation (P = 0.004) and the latter with ischemia (P < 0.01). Complications occurred in 23 (18.9%) children, esophageal stenosis being the most common. There were eight (6.4%) deaths, and only one recurrence 6 months after endoscopic management. The median follow-up period was 12 months. The inclusion of only case reports/case series, the incomplete reporting from papers, and the short follow-up were limitations of the study. CONCLUSIONS: GV occurs at a median age of 24 months and requires high suspicion and prompt management, as mortality is considerable. The preferred surgical approach for GV includes variations of gastropexy. Esophageal stenosis is the most common morbidity post-GV management.

Vascular and ventilatory mechanical responses in three different stages of pulmonary development in the rabbit model of congenital diaphragmatic hernia 1.

PURPOSE: To evaluate the vascular ventilatory response in different stages of lung development and to compare them to the neonates with congenital diaphragmatic hernia (CDH) in a rabbit model. METHODS: New Zealand rabbits were divided into 8 groups (n=5): E25, E27, E30, and CDH. All groups were ventilated on a FlexiVent (Scireq, Montreal, QC, Canada), compounding the other 4 groups. The CDH surgery was performed at E25 and the harvest at E30. Dynamic compliance (CRS), dynamic elastance (ERS) and dynamic resistance (RRS) were measured every 4 min/24 min. Median wall thickness (MWT) and airspace were measured. ANOVA Bonferroni tests were used to perform statistical analysis. Significance was considered when p<0.05. RESULTS: CRS was higher in E30 compared to all other groups (p<0.05). CRS and RRS of CDH and E27 were similar and were higher in E25 (p<0.05). MWT was decreased according to the gestational age, was increased in E27V and E30V (p<0.05) and decreased in CDHV (p<0.05), airspace was decreased in E25 and increased in all ventilated groups (p<0.05). CONCLUSIONS: The ventilation response of congenital diaphragmatic hernia is like the pseudoglandular stage of the lung development. These findings add information about the physiology of pulmonary ventilation in CDH.

Vascular and ventilatory mechanical responses in three different stages of pulmonary development in the rabbit model of congenital diaphragmatic hernia

Abstract Purpose: To evaluate the vascular ventilatory response in different stages of lung development and to compare them to the neonates with congenital diaphragmatic hernia (CDH) in a rabbit model. Methods: New Zealand rabbits were divided into 8 groups (n=5): E25, E27, E30, and CDH. All groups were ventilated on a FlexiVent (Scireq, Montreal, QC, Canada), compounding the other 4 groups. The CDH surgery was performed at E25 and the harvest at E30. Dynamic compliance (CRS), dynamic elastance (ERS) and dynamic resistance (RRS) were measured every 4 min/24 min. Median wall thickness (MWT) and airspace were measured. ANOVA Bonferroni tests were used to perform statistical analysis. Significance was considered when p<0.05. Results: CRS was higher in E30 compared to all other groups (p<0.05). CRS and RRS of CDH and E27 were similar and were higher in E25 (p<0.05). MWT was decreased according to the gestational age, was increased in E27V and E30V (p<0.05) and decreased in CDHV (p<0.05), airspace was decreased in E25 and increased in all ventilated groups (p<0.05). Conclusions: The ventilation response of congenital diaphragmatic hernia is like the pseudoglandular stage of the lung development. These findings add information about the physiology of pulmonary ventilation in CDH.

Surgical chylothorax in neonates: management and outcomes.

BACKGROUND: Postoperative chylothorax occurs due to trauma to lymphatic vessels and can occur after any thoracic procedure. This study reviewed recent literature to evaluate the management and outcomes of surgical chylothorax in neonates. METHODS: PubMed database was searched for articles in English, Portuguese and Spanish from 2000 to 2016. Data were collected for surgery, chylothorax management, complications, mortality and length of hospital stay (LOS). RESULTS: Twenty studies offered 107 neonates: congenital diaphragmatic hernia (CDH) (n = 76, 71%), cardiac malformations (n = 25, 23.4%), esophageal atresia (n = 5, 4.7%) and CDH + extralobar sequestration (n = 1, 0.9%). Medium-chain triglycerides (MCT) was the initial treatment in 52 neonates (48.6%), prednisolone + MCT in one (0.9%), total parenteral nutrition in 51 patients (47.7%), and three patients (2.8%) did not require any treatment. Octreotide and somatostatin were used as second or third line treatment in 25 neonates (23.4%), and 15 neonates (14%) underwent 17 surgeries, including thoracic duct ligation (TDL) (n = 9); pleurodesis (n = 3) (2 patients required TDL); TDL + pleurodesis (n = 2), and TDL + placement of hemostat (n = 1). Complications due to the chylothorax were reported in 27 neonates (25.2%): hypoalbuminemia + hyponatremia (n = 18), hypoalbuminemia (n = 4), hypoalbuminemia with cutaneous flushing as colateral effect of somatostatin (n = 1), loose stool after somatostatin use (n = 1), pneumonia (n = 1), congestive heart failure + hypernatremia (n = 1), and hyponatremia (n = 1). There were 21 deaths (19.6%) and median LOS was 53.4 days (30-93.1 days). CONCLUSIONS: Conservative management is appropriate as initial treatment for neonatal postsurgical chylothorax. Octreotide and somatostatin are safe in neonates and surgical approach should be considered in prolonged leaks.

Thoracoscopic Management of Blebs: Resection With/Out Primary Pleurodesis.

OBJECTIVES: To review the literature for justification of thoracoscopic management of blebs in children. METHODS: PubMed database was reviewed for articles in English, Portuguese and Spanish using the key words "thoracoscopy", "bleb" and "child". Data was collected for age, gender, type of surgery performed, operating time, conversions, complications, recurrences, follow-up and mortality. RESULTS: Eleven studies with total 266 patients were included (27 bilateral cases; n = 293 surgeries). Median age was 15.7 y (range 11-18 y), 225 were male (87.9%) and 31 were female (12.1%) patients. Endo GIA™ was used in 10 cases, Endoloop® in 11 surgeries, unspecified stapler devices in 150 procedures and, in 122 surgeries, instruments were not mentioned. Pleurodesis was performed in 213 (72.7%) cases. There were 5 (1.7%) conversions (adhesions n = 3, bleeding n = 1, camera failure n = 1). Complications were documented in 8 (2.7%): pneumothorax after chest tube removal 4 (drain reinsertion n = 3, reoperation n = 1); prolonged air leak 3, all submitted to che pleurodesis; bleeding requiring reoperation 1. Recurrence occurred in 25 (8.5%): 10 re-operation, 7 conservative management, 2 chemical pleurodesis, 2 chest tube reinsertions and in 4 the management was not specified. The median follow-up was 46.1 mo (range 3 mo-11 y). There were no lethal outcomes. CONCLUSIONS: Although data is scarce on specific instruments used, pleurodesis is performed in 70% of cases. Irrespective of this, thoracoscopic resection of blebs can be safely offered as it has a low complication and conversion rates and no mortality.