Emergencies in neonatal management: jaundice and biliary atresia

Biliary atresia is a severe and progressive inflammatory process of unknown cause, which initially involves the extrahepatic bile ducts but which quickly proceeds towards the intrahepatic bile tree leading rapidly to biliary cirrhosis. Biliary atresia is the major reason for liver transplantation during childhood. The extrahepatic bile ducts in biliary atresia become connective fibrotic cords which is irreversibly damaged

Unroofing and argon mucosal remnant ablation of neonatal duodenal duplication cyst

Abstract Background Duodenal duplication cyst is an uncommon foregut malformation usually diagnosed at birth or during infancy. Differently from elsewhere, sited small bowel duplications cannot be removed with simple bowel resection, because of the proximity of the biliary and pancreatic ducts also possibly with abnormal course. Case presentation We report a duodenal duplication cyst in a newborn female requiring early surgery because of nutritional difficulties. The cyst was located adjoined to the second portion of the duodenum sharing part of its muscle wall with the bowel. It was treated by removal of all the esophytic cyst while the remaining mucosa on the common wall with the duodenum was ablated with argon plasma coagulation, preserving the bowel integrity. Early postoperative period was uneventful, and the child could be fed per os on the second day. Yearly follow-up was maintained until 16 years for the risk of recurrence and cancer change due to the incomplete excision. Clinic and echographic controls had always been stayed free from any sequelae. Conclusions Foregut duplications should be removed totally to prevent complications and the long-term risk of cancer, but a duodenal resection can be a harmful surgery in neonatal age. Duplication cysts that are impossible to remove totally can be treated by unroofing and argon plasma coagulation of mucosal surface remnants, avoiding the risks of major procedures also in newborns

Laparoscopic Ist stage orchiopexy using antiadherent sheet for high abdominal testis

Abstract High undescended testes with short spermatic vessels are not treated with standard orchiopexy and are currently brought to scrotum prevalently after the section of spermatic vessels, according to the Fowler-Stephens procedure. The ischemic risk of that method is elevated and becomes unbearable in bilateral cases. In 2009 an original staged orchiopexy technique was proposed to elongate the whole cord with anti-adherent sheet preserving the spermatic vessels by which a normal scrotal position was successfully gained without any testis loss. Both stages were performed through inguinotomy. In the present article the successful procedure is updated with implementation of laparoscopy in the first stage in a case of extremely high bilateral 4a type abdominal testis. Laparoscopic access was confirmed as valuable both in terms of extended mobilization and coverage of the entire testis vascular supply. The method of progressive cord elongation by using an anti-adherent sheet avoids the excessive atrophy hazard deriving from the Fowler-Stephens procedure in bilateral high abdominal 4a type testes; based on our findings, the latter can benefit also of a laparoscopic approach in the first stage

PROPOSTA DE INTERVENÇÃO PARA A MENSURAÇÃO DA EFETIVIDADE DOS CANAIS DE MÍDIAS ATRAVÉS DOS LEADS DE UMA REVENDA DE AUTOMÓVEIS NA CIDADE DE CASCAVEL-PR

Este relato técnico-científico tem o objetivo diagnosticar a mensuração da efetividade dos canais de mídias através dos leads de uma revenda de automóveis na cidade de Cascavel-PR. Na metodologia, utilizou-se da pesquisa de caráter exploratório e descritivo, com um estudo de caso para evidenciar as vendas efetivas, através das estratégias de marketing utilizadas pela empresa. Usou-se uma abordagem qualitativa nos dados coletado no sistema da empresa, para perceber o real impacto dos canais de mídias. Para isso foi necessário o uso do Customer Relationship Management- CRM- Revenda Mais, versão Demo e o uso do Softwares Microsoft Excel 2010, que obteve os resultados estratificados dos canais de mídias que a empresa utiliza e criou-se uma ferramenta para melhorar a tomada de decisão com o marketing. Os dados apontaram que a empresa está adotando ações de marketing de forma generalizada na divulgação de automóveis através vários canais de mídias. Com a proposta de intervenções espera-se melhorar a gestão destes canais na venda de automóveis, melhorando o marketing e das ações estratégicas da empresa, contribuindo para o alcance de seus objetivos

Labial mucosa and combined labial/bladder mucosa free graft for urethral reconstruction

One-stage urethral reconstruction was performed using a free graft of labial mucosa and combined labial/bladder muscosa. We present the results of this technique in 12 cases that had a minimum follow-up period of 3 years. Eleven patients had medium penile or posterior hypospadias and one had chordee penis without hypospadias. Urethroplasty with labial mucosa was performed by two techniques: labial mucosa used alone or combined with bladder mucosa. The labial mucosa was harvested from the inner surface of the upper and/or lower lip, depending on which method was used. Seven patients, six with medium penile or posterior hypospadias and 1 with chordee without hypospadias, were given a labial mucosa graft alone; the urethral gap was 3.5 to 6 cm. The other five cases, all with posterior hypospadias, were treated by combined labial/bladder mucosa graft urethroplasty; the urethral gap was 6 to 13 cm. Follow-up (at 3 to 4½ years) showed no complications apart from a urethral fistula in one patient and mild stenosis on the anastomosis in four cases, which required urethral dilatations in the first month after surgery

Pedicled jejunal interposition as esophageal substitute in pediatric patients. Technical considerations and long-term results

Abstract The current study reports the surgical technique and the clinical long term results of pediatric esophageal substitution with a pedicled jejunal loop in two patients with long gap esophageal atresia and one patient with severe esophageal stenosis due to a caustic lesions. Postoperative course was uneventful in all patients. At a long term follow-up of 29 and 43 years for the patients with esophageal atresia and 21 for the one with caustic stenosis, no feeding troubles were reported due to malfunction of the esophageal replacement nor to loss of its original functions and the patients referred a highly satisfying quality of life. Pedicled jejunal interposition confirms as a good substitute of the esophagus in pediatric age with the advantage to maintain good performances for very long time. Although these patients do not share the same risks of illness as other patients still harboring their native pathologic esophagus, a far sighted surveillance is recommended due to long term potential morbility risk

Reconstruction of hypospadias and epispadias with buccal mucosa free graft as primary surgery: more than 10 years of experience

Purpose: The most common techniques to reconstruct the urethra for severe hypospadias or epispadias involve use of the genital skin. Buccal mucosa free graft is usually used in a second operation due to a paucity of usable genital tissue. We report our experience using buccalmucosafreegraft as primary surgery for hypospadias and epispadias. Materials and Methods: Between 1989 and 2001 the urethra was reconstructed using buccal mucosa free graft as a primary operation in 22 patients 3 to 13 years old with middle or proximal hypospadias (20) and exstrophy/epispadias (2). In the first 5 cases of hypospadias the buccal mucosa was combined with bladder mucosa. In the 2 exstrophy/epispadias cases treated with the penile disassembly technique the distal part of the urethra was reconstructed with buccal mucosa. Results: At mean 5-year followup 2 cases of urethral fistulas and 1 case of severe stenosis of the proximal anastomosis were observed, which required surgical correction. In 4 other cases mild stenosis of the anastomosis required urethral dilations in the first month after surgery. Conclusions: Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties as primary surgery. It is readily available, elastic, resistant and technically easy to harvest.</br

Experimental use of labial mucosa free graft urinary conduit in the Mitrofanoff principle

Purpose. One method of treating urinary incontinence is to create a catheterizable and continent vesicostomy by the Mitrofanoff principle, based on the use of a conduit, which in the original method is the appendix. The authors present an experimental technique in which a continent vesicostomy is created by the Mitrofanoff principle, using a conduit made of a labial mucosa free graft. Methods. Six 30-day-old pigs underwent surgery to create a continent vesicostomy by the Mitrofanoff principle. A tube, made of labial mucosa free graft from the lower lip, was used. The labial mucosal conduit was anastomosed to the bladder mucosa. The tunnel was then prepared, part of which passed through the fibers of the right rectus muscle. The conduit was taken through the tunnel and anastomosed to the skin in the right iliac fossa. Results. Fifty days after the operation, the vesicostomy was continent, pervious, and easily catheterizable in 5 animals. In the sixth pig, the cystostomic tube did not graft successfully because it was infected. Conclusions. A number of investigators have extrapolated Mitrofanoff method using the ileum, the ureter, or others. The use of a tube made by labial mucosa free graft is an easily performed technique, and as with the Mitrofanoff method, continence and easy catheterization are successfully achieved

Correction of congenital chordee penis by "Ventral separation and outward rotation of corpora"

Background/Purpose: The formation of congenital chordee penis in patients with or without hypospadias is multifactorial and not completely clear. In most cases, after release of all known causes of chordee, “residual” penile curvature can persist. The authors discuss the etiopathogenetic mechanisms of congenital chordee penis and describe their experience in surgical correction of “residual” penile curvature by “ventral separation and outward rotation of corpora.” Methods: In 22 patients with congenital chordee penis with or without hypospadias, “residual” penile curvature was corrected by “ventral separation and outward rotation of corpora.” Results: Ventral separation and outward rotation of corpora resulted in satisfactory correction of penile curvature. In only 2 cases of chordee penis without hypospadias was further intervention necessary: a Nesbit’s plication was carried out in one and a neourethra placed in the other. At follow-up no residual penile curvature was observed. Conclusions: An arrest of development of the penis caused by failure of outward ventral rotation of the corpora, may contribute to the formation of chordee penis. When “residual” penile curvature persists, “ventral separation and outward rotation of corpora” can be used to correct this complex malformation.</br

Simplified video-assisted one-trocar diverting colostomy in pediatric patients

Background: In pediatric age colostomy is mainly temporary and totally diverting, the major indication being neonatal anorectal malformation for which a specific double separated stoma route has been widely popularized. Out of newborn age the reasons for colon diversion in children are less common and the procedures are quite similar to the techniques employed in adults. Laparoscopy for pediatric colostomy has a short history and the original recommended procedure for newborns has been achieved only very recently with a two-trocars technique. Methods: We describe an original one-trocar method to create a double or single totally diverting colostomy avoiding any other abdominal wound at risk for complications. The procedure has been performed on newborns with anorectal malformations as well as on a teenager through minor technical variants. Results: This one-trocar method allowed a quick and safe totally diverting colostomy in every treated patient. There was no complication during surgery and no skin infection in the whole postoperative period; at the end of treatment scars were minimal. Conclusions: This technique is suitable for the specific neonatal double separated colostomy and virtually for every indication of fecal stream diversion in any kind of patient