Comparación entre la cirugía videolaparoscópica y la cirugía abierta para las enfermedades renales benignas en el niño / Comparison of videolaparoscopic versus open surgery for benign renal diseases in Children

Introducción: La nefrectomía laparoscópica en niños se ha convertido en una alternativa razonable a la nefrectomía abierta y ha sustituido a la cirugía abierta en muchas enfermedades renales. El objetivo de nuestro estudio es evaluar los procedimientos videolaparoscópicos transperitoneales en las enfermedades renales benignas en comparación con el abordaje quirúrgico abierto. Pacientes y método: 34 niños de edades comprendidas entre los 17 días y los 15 años (media, 6, 14 años) fueron divididos en dos grupos de nefrectomía; el primero fue sometido a nefrectomía videolaparoscópica transperitoneal y estaba compuesto por 21 pacientes (12 mujeres y 9 varones) con edades comprendidas entre los 2 meses y los 15 años (media, 7, 42 años). El segundo grupo fue sometido a nefrectomía abierta y estaba compuesto por 13 pacientes (6 mujeres y 7 varones) con edades comprendidas entre los 17 días y los 11 años (media, 3,91 años). Los grupos se compararon respecto al tiempo de anestesia, el tiempo operatorio, la duración de la estancia hospitalaria, el dolor postoperatorio y el tiempo de reinstauración de la ingesta oral. También se evaluaron las complicaciones acorto y largo plazo. El análisis estadístico se llevó a cabo mediante la prueba de la t de Student, y se estimó significativo el valor de p < 0,05. El Comité de Ética Científica de nuestra institución aprobó previamente el estudio. Resultados: Se observaron diferencias estadísticamente significativas sólo en cuanto a la variable duración de la estancia hospitalaria. Ningún caso del grupo a laparoscopia se convirtió en cirugía abierta. No se observaron complicaciones inmediatas ni tardías. La pérdida de sangre fue insignificante y no fue necesario administrar transfusiones. Conclusiones: Según nuestra experiencia, la nefrectomía videolaparoscópica transperitoneal presenta resultados similares a los de la nefrectomía abierta, excepto en lo que respecta al tiempo de hospitalización (AU)

Introduction: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many renal diseases. The purpose of our study is to evaluate transperitoneal videolaparoscopic procedures in renal benign diseases in comparison to an open surgery approach. Patients and methods: 34 children aged between 17 days and 15 years old (mean 6.14) were divided into two groups in order to be submitted to nephrectomy. The first one underwent transperitoneal videolaparoscopic nephrectomy and was composed by 21 patients aged from 2 months to 15 years (mean 7.42), from which 12 were females and 9 males. The second group was submitted to open nephrectomy and was composed by 13 patients aged from 17 days to 11 years (mean 3.91), 6 females and 7 males. The groups were compared regarding anesthesic time, operative time, length of hospital stay, postoperative pain and time of reintroduction of oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by Student t-test with the level of significance set at P < 0.05. The study was previously approved by the Committee on Ethics in Research of our institution. Results: Significant statistical difference was observed only for the variable length of hospital stay. No laparoscopy group case was converted to open surgery. There was no immediate or late complication. Blood loss was negligible and no transfusion was required. Conclusions: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to open nephrectomy, except for time of hospitalization (AU)

Comparison of videolaparoscopic versus open surgery for benign renal diseases in children.

INTRODUCTION: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many kidney diseases. The aim of our study is to evaluate transperitoneal videolaparoscopic procedures in benign renal disease compared with the open surgical approach. PATIENTS AND METHODS: 34 children aged between 17 days and 15 years (mean, 6.14 years) were divided into two nephrectomy groups. The first underwent transperitoneal videolaparoscopic nephrectomy and was composed of 21 patients (12 female and 9 male) aged between 2 months and 15 years (mean, 7.42 years). The second group underwent open nephrectomy and was composed of 13 patients (6 female and 7 male) aged between 17 days and 11 years (mean, 3.91 years). The groups were compared for time of anaesthesia, operating time, length of hospital stay, postoperative pain and time to restore oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by a Student's t test, with a p value < 0.05 being considered significant. The study was approved beforehand by the Scientific Ethics Committee in our institution. RESULTS: Statistically significant differences were observed only for the length of hospital stay. No cases in the laparoscopic group were converted into open surgery. There were no immediate or late complications. Blood loss was negligible and so it was not necessary to administer any transfusions. CONCLUSIONS: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to those of open nephrectomy, except for hospitalisation times.

Surgical treatment for recurrent refractory skenitis.

We report a case of persistent skenitis that was initially misdiagnosed and treated as a urinary infection. Despite an adequate course of antibiotics, the symptoms failed to improve. The case was ultimately resolved with surgical intervention, which resulted in its prompt and complete resolution.

Extraperitoneal access for kidney transplantation in children weighing 20 kg. or less.

PURPOSE: We present our experience with kidney transplantation in children weighing 20 kg. or less. Surgery was done via extraperitoneal access while preserving the peritoneal cavity intact with special attention given to technical feasibility and the complication rate. MATERIALS AND METHODS: Included in our study were 46 children with a median age of 7 years weighing 20 kg. or less (mean 16.6), of whom 16 weighed less than 15 kg. (median 13.2). The 25 boys and 21 girls underwent a total of 49 kidney transplants, including 2 in 3 during the study. Donors were living related in 44 cases and cadaveric in 5. Surgical access was obtained by making a J-shaped pararectal incision in a curvilinear fashion from the symphysis pubis to near the costal border. RESULTS: Mean hospital stay was 22.9 days (range 6 to 83) and mean followup was 55.8 months (range 12 to 131). All patients received water on day 1 and food on day 2 postoperatively. In 6 patients 7 surgical complications developed, including urinary fistula in 2, superficial wound infection in 2 and vascular complications in 3 (renal vein thrombosis, stenosis and renal artery kinking in 1 each). Only 1 graft was lost due to a surgical complication. CONCLUSIONS: There are many advantages to using extraperitoneal access without an increase in surgical complications or technical difficulty. Absent gastrointestinal complications, an easier way to perform percutaneous biopsy, treatment of any surgical complication with no need for repeat laparotomy and the possibility of using the peritoneal cavity when dialysis is needed postoperatively are attractive justifications for extraperitoneal access.

Kidney transplantation: the use of living donors with renal artery lesions.

PURPOSE: A shortage of organs for transplantation has forced surgeons to optimize the use of marginal organs, such as kidneys with arterial disease. We present a retrospective study of the outcome of donors with renal artery disease and recipients of kidneys from living related and unrelated donors. MATERIALS AND METHODS: Kidneys with vascular abnormalities from healthy living donors were grafted into 11 recipients. These kidney transplants comprised 1.8% of those performed at our institution. The vascular abnormalities were aneurysms in 3 cases, atherosclerotic lesions in 4 and fibromuscular dysplasia in 4. After nephrectomy all abnormalities were corrected under hypothermic conditions during bench surgery except in 3 cases of ostial atherosclerotic plaque, which was left in the donors. The renal artery was anastomosed to the external iliac artery in 5 cases and to the internal iliac artery in 6. The ureter was reimplanted using an extravesical technique. RESULTS: All patients had immediate diuresis and no delayed post-transplant graft dysfunction was observed. One patient died of an unrelated cause and 3 had post-transplant graft function loss due to acute vasculopathy in 1, post-diarrhea with acute arterial thrombosis in 1 and recurrence of the hemolytic-uremic syndrome in 1. All remaining patients are well with median serum creatinine of 1.4 mg./dl. (normal 0.4 to 1.4). All donors are well and normotensive with normal renal function. CONCLUSIONS: The use of kidneys with arterial disease from living donors with unilateral disease is safe. Complete informed consent regarding the risks and benefits by donor and recipient is mandatory.

DNA image cytometric analysis of differentiated thyroid adenocarcinoma specimens.

A total of 117 differentiated thyroid adenocarcinomas that had been removed by total thyroidectomy were studied. Seventy (60%) were papillary, 36 (30%) were follicular, and 11 (10%) were Hürthle cell adenocarcinomas. The mean length of follow-up was 57.7 months. Adverse prognostic factors according to multivariate analysis were adjacent tissue infiltration (p = 0.0004), histologic type (p = 0.0049), and patient age (p = 0.033). The nuclear DNA content of tumor cells and of morphologically normal adjacent tissue was assessed by image cytometry, and correlations between nuclear DNA content and prognostic factors were examined. Fifty-four (75%) adenocarcinomas were classified as aneuploid, 9 (13%) as diploid, and 9 (12%) as borderline. Thirty-four (60%) specimens of morphologically normal adjacent tissue were classified as aneuploid, 18 (32%) as diploid, and 5 (8%) as borderline. The correlation between tumor ploidy and selected prognostic factors was statistically significant for patient age (p = 0.004) and histologic type (p = 0.033). Despite the fact that ploidy could not be identified as a prognostic factor, we suggest that, because of its correlation with age and histologic type, it might prove prognostic if the number of patients were increased. We also emphasize the importance of evaluating morphologically normal adjacent tissue because of the high rates of aneuploidy in these areas.

Intestinal anastomoses.

Anastomotic dehiscence remains the main cause of morbidity and mortality of intestinal resections, mainly the colorectal (77, 95, 110). Very often in the literature the words dehiscence and fistula are misused for the same meaning. Nevertheless, attention must be paid to the fact that these two situations may be distinct. Dehiscence is defined as the failure of healing of the anastomoses, while fistula is the leakage of the intestinal content into the peritoneal cavity. So, the evidence of fistula is always accompanied by dehiscence, although a dehiscence may not develop into a fistula, should it be blocked by omentum or surrounding organs (110, 117). The incidence of overt dehiscence varies from 0.1% to 30% in the literature (13, 15, 17, 27, 31, 40, 44, 46, 76, 77, 81, 96, 113, 120, 123, 126, 133, 135). The Colon Cancer Project of the Saint Mary's Hospital in London, a multicentric study of patients submitted to bowel resections revealed a post operative mortality of 22% in patients with dehiscence and 7% for uncomplicated anastomoses. This led to the struggle various authors to achieve better results, regarding techniques and suture materials, such as the number of planes involved, inverted or everted sutures, wound healing and the influence of local and systemic factors, like infections, antibiotics, NSAIDs on sutures. Recently, surgical stapling gained importance among surgeons, due to its technical advantages. However, this is still very controversial and must undergo further investigations (93, 107, 109, 112, 115, 116). So, in order to understand the pathophysiology of the complications and to reduce morbidity and mortality, related to intestinal anastomoses, it is necessary to study the events involved in intestinal healing after resection, as well as the technique, materials used and the factors related to anastomotic failure.