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Laparoscopic partial splenectomy in pediatric patients
No full textChildren with hematological disease ,which can have beneficial from a partial and/or total splenectomy, may be divided into three major groups. The first group includes the congenital hemolytic anemias in which the spherocytosis plays a significant role. The second group concerns the hemoglobinopathies especially thalassemia major and sickle cell disease (SCD), and the third the acquired immune-hematological disorders such as autoimmune hemolytic anemia and thrombocytopenic purpura. Taking into account the focus of this meeting, the partial splenectomy, it seems appropriate to underline the primary physiological rules of the spleen as an organ of the reticuloendothelial system: the filter function, the hemocatheresis and the bacteria phagocytosis. This last activity, which is part of the immunological function, regards the antigen specific immune response to the production of opsonine, that allows phagocytosis of polysaccharidic bacteria, the main source of sepsis for splenectomized patients. Total splenectomy exposes the patients to a higher risk of sepsis as well the age: children with an age less than five years-old have a 10 % risk of serious infections compared to 1-2% of an adult. We know from the experience that the underlying disease, such as thalassemia, can increases this risk up to a maximum risk of 1,000 times higher than the risk of 50 of post-trauma splenectomised patient. Looking over hematological indications for splenectomy, these have the main objective to remove the hemocatheresis function of the spleen. The main question is whether the partial splenectomy can preserve the immune function abolishing that of hemocatheresis. A removal of 75% of the splenic volume allows to maintain an immunological response to the pneumococcal stimulus. Hematological and immunological studies have shown that in the patients where partial splenectomy have been performed, the production of immunoglobulins and lymphocytes is maintained with good results. Even in experimental models, when the 75% of the weight of the spleen is removed, they have a preservation of the reticulo-endothelial function, as well as the index of phagocytosis in response to the pneumococcal infection. This feature is not present in the experimental model of auto-transplant splenic tissue due to the vascular modifications that does not allow to preserve the immunological function. Going back to hemocatheresis, we know that an indication to partial splenectomy is spherocytosis, which we classify into different levels of severity according to hemoglobin, reticulocyte and bilirubin values. The splenectomy is reserved for severe patients, which account for approximately 10-15% of all forms of spherocytosis but the objective is to postpone at least till the age of 5-6 years the timing of the surgery. In the long term follow-up of these patients, Hb values remain stable over time, as well as the reticulocyte count, although the hemolysis is not entirely abolished. If we look in detail to the splenic remnant, we may observe a recurrence of hypersplenism, that still tends to increase over the years, although this does not appear to affect the hematologic parameters of these patients; once again the growth of the spleen, accompanied by a restructuring of the parenchyma and vascular flow seems not to have a significative influence in these patients. Comparing papers on spherocytosis, the risk of recurrence of hypersplenism is also reported with a small number of patients requiring a total splenectomy. This procedure has been performed with good results also in patient with thalassemia major, although some Authors highlight that this procedure might have only a temporary effect, due to the presence of the residual splenic tissue that can grow in the following years; but at the mean time, this decision could be considered especially at a young age when these children are more sensitive to the infections of capsular bacteria. Considering sickle cell disease and guidelines of the onco-hematology pediatric community, the level of evidence, as well as the indication for the surgery becomes more restrictive; the partial removal of the spleen provides an efficient volume reduction, the need for transfusions and reduces the risk of splenic sequestration. In these patients the clinical picture is more complex as sickle cell disease involves a risk of having splenic infarction; furthermore, despite an appropriate splenic volume we have kids with reduced or functional asplenia where the immunological function is compromised. A report comparing the partial splenectomy with total laparoscopic to open surgery, shows that there are many, non randomized, prospective studies with heterogeneous data; the hematologic outcome has been analysed showing comparable results with partial and total splenectomy. With regard to the immunological function, the partial splenectomy appears to preserve the activity of phagocytosis. Significative differences were not observed between the open and the laparoscopic approach. In the last group of acquired immunological splenic diseases, the development of immunosuppressive therapies has reduced the indications to the splenectomy. In conclusion, we have still some open questions: partial splenectomy has always an indication or conversely, we must observe some criteria such as a younger age of 5-6 years? Some authors have suggested to reserve this approach to patients that for geographical or logistical reasons do not have a transfusion support and / or a poor antibiotic prophylaxis compliance. A further question to be considered is: the partial splenectomy, preserving the hematological function, could avoid in these patients, the antibiotic prophylaxis and pre-splenectomy vaccinations? Based on the American group’ experience, however, antibiotic prophylaxis is recommended for at least one year and still are carried out vaccinations, doubting the long-term effect of the partial splenectomy
Circulatory and metabolic effect of anemia in hyperinsulinemic ovine fetuses
No full textInfants born to women with poorly controlled diabetes mellitus have an increased incidence of perinatal asphyxia, cardiovascular abnormalities, elevated catecholamines, and sudden fetal death. Although hyperinsulinemic fetuses of diabetic women often exhibit polycythemia, they may also develop anemia because of pregnancy- and/or delivery-related complications. Experimental fetal hyperinsulinemia results in cardiovascular changes and a surge in catecholamines. We hypothesized that reductions in fetal O2 availability via anemic hypoxia limits O2 transport and compromises the hemodynamically and metabolically stressed but compensated hyperinsulinemic fetus. Chronically catheterized fetuses receiving insulin (n = 9) or placebo (n = 5) for 48 h were rendered anemic by an isovolemic exchange transfusion. In the hyperinsulinemic state, anemic-hypoxia augmented the insulin-mediated surge in norepinephrine concentration and increases in blood flow to brain, heart, and adrenal glands. Insulin-related increase in the combined ventricular output was sustained during anemia. O2 delivery to the fetus decreased, extraction increased, and O2 uptake did not change. Regional O2 delivery to the brain, kidney, gastrointestinal tract, muscle, fat, pancreas, spleen, and carcass decreased. Hyperinsulinemic ovine fetus exposed to anemic hypoxia demonstrated an accentuated surge in norepinephrine, a sustained increase in the combined ventricular output, preservation of systemic O2 uptake, and compromised regional O2 delivery to certain vascular regions. We conclude that the hyperinsulinemic fetus was able to compensate for anemic hypoxia by increased or sustained regional vascular perfusion
Self Amputated Ovarian Cyst: An Unexpected Laparoscopic Finding
No full textToday laparoscopy is necessary in the diagnostic and therapeutic management of abdominal masses also in neonatal period. We report the case of a 28 days old girl admitted in our department with a prenatal diagnosis of abdominal mass. The ultrasound and CT scan revealed a 4 cm cyst in the right superior abdominal region. Instead the MRI revealed the mass localized in the right iliac region. A diagnostic laparoscopy with an open transumbilical approach was performed, that revealed an intra-abdominal 5 cm cystic formation with a thin vascular bundle. A minimal laparotomy was performed and the cyst removed. The histological examination indicated a self amputated ovarian cyst. Laparoscopy is proved to be a significant contribution in the diagnosis of abdominal masses because it allows a correct diagnosis and to plan the best management
One-trocar-assisted pyeloplasty: An attractive alternative to open pyeloplasty
Full text linkBackground: To survey the effects of one-trocar-assisted pyeloplasty (OTAP) in the treatment of ureteropelvic junction obstruction (UPJO) in kids. Materials and Methods: Forty-four children (±3.5 years) were submitted to OTAP procedure. A flank incision under the XII rib was made, the Gerota′s fascia was achieved and a balloon Hasson trocar with an operative telescope inserted for retroperitoneal access. The renal pelvis and ureter were isolated and exteriorised. Forty-two patients underwent Anderson-Hynes dismembered and one Fenger pyeloplasty . One patient was converted to an open procedure. Two patients presented an aberrant crossing vessel. In all patients, a double J stent was positioned. The operative time and length of stay (LOS) were evaluated. Renal scan and ultrasound (US) were utilised to evaluate the results from 6 to 12 months. Results: OTAP was successful in all but 1 patient. Mean operative time and LOS were 128 min and 3,5 days. We had four operative complications (9.09%). The US and a nuclear scan confirmed the resolution of the UPJO in all patients except one with the Fenger pyeloplasty who had an open Anderson-Hynes. Conclusions: The combination of retroperitoneoscopic and open procedures for dismembered pyeloplasty offers a simple, time-saving method in a minimally invasive fashion with low morbidity for patients with UPJO
LAPAROSCOPY FOR NON PALPABLE TESTIS: IS INGUINAL EXPLORATION ALWAYS NACESSARY WHEN THE CORD STRUCTURES ENTER THE INGUINAL RING?
Full text linkLaparoscopic surgery in children: abdominal wall complications
No full textMinimal invasive surgery has become the standard of care for operations
involving the thoracic and abdominal cavities for all ages. Laparoscopic complications can
occur as well as more invasive surgical procedures and we can classify them into non-specific
and specific. Our goal is to analyze the most influential available scientific literature and to
expose important and recognized advicesin order to reduce these complications. We examined
the mechanism, risk factors, treatment and tried to outline how to prevent two major abdominal
wall complications related to laparoscopy: bleeding and port site herniatio
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