Estimation of prognosis in patients after decompressive craniectomy after malignant hemispheric infarction: multifactorial scoring scale.

BACKGROUND: Patient's age is considered to be one of the most relevant factors in selecting surgical candidates for decompressive hemicraniectomy after malignant hemispheric infarction. However, questions about surgical indication in older patients, patients with consciousness disorder or patients with large infarctions remain unanswered. OBJECTIVE: Our aim was to design a multifactorial scoring scale based on a combination of patient-specific factors in order to optimize the assessment of prognosis in patients after hemicraniectomy malignant strokes. METHODS: In this prospective observational study with a one-year follow-up, we assessed clinical and imaging data of patients who underwent decompressive hemicraniectomy due to malignant brain infarction. Barthel index was used as a single outcome measure to distinguish favorable vs. unfavorable outcomes. Associations between multiple variables and clinical outcome were assessed. Subsequently, a design of a predictive scoring system was proposed. RESULTS: Age of the patient, preoperative level of consciousness, midline shift, and volume of infarction showed a significant association with postoperative Barthel index. According to the identified factors, a multifactorial prognostic scoring system was introduced, aimed to distinguish between favorable and unfavorable outcomes. Using ROC analysis, it has achieved an AUC of 0.74 (95%CI 0.58‒0.89, p=0.01)CONCLUSIONS: Prediction of postoperative outcome should be based on multiple variables. Our scale, based on the clinical and imaging data, can be used during decision-making to estimate potential benefit of decompressive craniectomy in patients after malignant brain infarction (Tab. 5, Fig. 1, Ref. 32). Text in PDF www.elis.sk Keywords: decompressive hemicraniectomy, malignant hemispheric infarction, indication, outcome, prediction.

Inanimate 3D printed model for thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

Background: Thoracoscopic repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) poses significant technical challenges. This study aimed to develop an inexpensive, reusable, high-fidelity synthetic tissue model for simulating EA/TEF repairs and to assess the validity of the simulator. Methods: By using 3D printing and silicone casting, we designed an inexpensive and reusable inanimate model for training in thoracoscopic EA/TEF repair. The objective was to validate the model using a 5-point Likert scale and the Objective Structured Assessment of Technical Skills (OSATS) to evaluate participants' surgical proficiency. Results: A total of 18 participants (7 medical students, 4 pediatric surgery trainees, and 7 experienced surgeons), after being instructed and trained, were asked to perform TEF ligation, dissection, as well as esophageal anastomosis using six sliding knots on the EA/TEF simulator. All participants in the expert group completed the task within the 120-minute time limit, however only 4 (57%) participants from the novice/intermediate completed the task within the time limit. There was a statistically significant difference in OSATS scores for the "flow of task" (p = 0.018) and scores for the "overall MIS skills" (p = 0.010) task distinguishing between novice and intermediates and experts. The simulator demonstrated strong suitability as a training tool, indicated by a mean score of 4.66. The mean scores for the model's realism and the working environment were 4.25 and 4.5, respectively. Overall, the face validity was scored significantly lower in the expert group compared to the novice/intermediate groups (p = 0.0002). Conclusions: Our study established good face and content validity of the simulator. Due to its reusability, and suitability for individual participants, our model holds promise as a training tool for thoracoscopic procedures among surgeons. However, novices and trainees struggled with advanced minimally invasive surgical procedures. Therefore, a structured and focused training curriculum in pediatric MIS is needed for optimal utilization of the available training hours.

Laparoscopic management of the congenital chylous ascites in a newborn: Case report.

Congenital chylous ascites (CCA) is a rare condition seen in the neonatal period. The pathogenesis is primarily related to congenital intestinal lymphangiectasis. Conservative treatment of chylous ascites involves paracentesis, total parenteral nutrition (TPN), medium-chain triglyceride (MCT)-based milk formula, use of somatostatin analogue and octreotide. Surgical treatment is considered when conservative treatment fails. We describe a laparoscopic treatment of CCA using the fibrin glue technique. A male infant, in whom foetal ascites was detected at 19 weeks of gestation, was born by caesarean section at 35 weeks of gestation weighing 3760 g. There was evidence of hydrops in the foetal scan. A diagnosis of chylous ascites was made by abdominal paracentesis. A magnetic resonance scan was suggestive of gross ascites, and no lymphatic malformation was identified. TPN and octreotide infusion was started and continued for 4 weeks, but the ascites persisted. The failure of conservative treatment led us to perform laparoscopic exploration. Intraoperatively, chylous ascites and multiple prominent lymphatic vessels around the root of the mesentery were noted. The fibrin glue was applied over the leaking mesenteric lymphatic vessels in the duodenopancreatic region. Oral feeding was started from post-operative day 7. After 2 weeks of the MCT formula, ascites progressed. Thus, laparoscopic exploration was necessary. We introduced an endoscopic applicator for fibrin glue and applied it into the place of leakage. The patient was doing well with no appearance of ascites reaccumulating and was discharged on the 45th post-operative day. Follow-up ultrasonography (1st, 3rd and 9th months after discharge) showed a small amount of ascitic fluid but with no clinical significance. Laparoscopic localisation and ligation of leakage sites could be difficult, especially in newborns and young infants due to the small size of lymphatic vessels. The use of fibrin glue to seal the lymphatic vessels is quite promising.

Plasma concentrations of levobupivacaine in neonates during caudal epidural analgesia maintained over 48 hours.

BACKGROUND: Differences in neonatal pharmacokinetics are known to cause systemic accumulation of levobupivacaine with adverse effects during epidural analgesia. Therefore, it is not recommended to surpass 48 hours of administration in neonates. Free and total levobupivacaine levels are considered as predictors of toxicity. OBJECTIVE: The aim of the LEVON pilot study was to detect the accumulation of levobupivacaine during epidural analgesia exceeding 48 hours in neonates. METHODS: Ten neonates received a loading dose of levobupivacaine (1.25 mg/kg) followed by a continuous infusion (0.2 mg/kg/hour) epidurally. Free and total levobupivacaine concentrations were measured 0.5, 1, 6, 12, 36, 72 and 144 hours after the start of infusion. Cumulative doses of levobupivacaine, pain scores and clinical signs of toxicity were used for assessing efficacy and safety. RESULTS: The median concentrations of total levobupivacaine were 586.0, 563.0, 837.5, 957.0, 1930.0, 708.5 and 357.5 ng/ml. The median concentrations of free levobupivacaine were 4.0, 3.6, 5.5, 3.6, 5.5, 0.8 and 0.0 ng/ml. Three patients reached concerning concentrations of total levobupivacaine. Levels of free levobupivacaine remained low. No signs of toxicity were observed. CONCLUSION: Caudal epidural analgesia with levobupivacaine lasting longer than 48 hours appears to be safe providing that free levobupivacaine levels are below the presumed threshold for toxicity (Tab. 1, Fig. 1, Ref. 29). Text in PDF www.elis.sk Keywords: free levobupivacaine, total levobupivacaine, neonate, caudal continuous epidural analgesia, postoperative pain.

Lethal hemorrhagic necrotizing pancreatitis in a child with congenital immunodeficiency and COVID-19.

Purpose: Various manifestations of coronavirus (SARS-CoV-2) have been reported since the pandemic began. Some articles have reported acute pancreatitis in adult patients due to COVID-19 infection. To our knowledge this is the first report of acute hemorrhagic necrotizing pancreatitis in children associated with SARS-CoV-2 infection. Case presentation: A 7-year-old girl with congenital immunodeficiency was referred to the intensive care (ICU) unit with acute respiratory distress syndrome. She required mechanical ventilation (MV) due to pulmonary involvement of COVID-19 (chest CT with lower lung ground-glass opacities). SARS-CoV-2 infection was laboratory confirmed. Following a 49-day stay in the ICU, due to the clinical and radiological signs of acute abdomen and to the rapid deterioration in the clinical status, an indication to proceed an urgent surgerical intervention was made. Intra-operatively an adhesiolysis with blunt dissection of the of gastrocolic ligament was performed, then followed by debridement of the necrotic pancreas (more than 1/2 of the pancreas was damaged). Continuous lavage and drainage were placed. During the post-operative period, patient required aggressive MV and insulin therapy for persistent hyperglycemia. The CT scans reported a necrosis of the pancreas and we observed amylase and lipase elevation in the peritoneal lavage sample. Despite active intensive therapy, the patient's condition did not improve and she died 38 days after laparotomy as a result of multi-organ failure. Conclusion: The mechanism for the development of acute haemorrhagic necrotizing pancreatitis in the COVID-19 positive patients is unclear; perhaps it is due to a direct cytopathic effect from the COVID-19 virus, or due to the ACE2 expression in pancreas.