Συστηματική ανασκόπηση και μετά-ανάλυση των ελάχιστα επεμβατικών τεχνικών στην αντιμετώπιση της αχαλασίας του οισοφάγου στα παιδιά

Εισαγωγή. Η αχαλασία οισοφάγου (ΑΟ) είναι μια σπάνια διαταραχή της κινητικότητας του οισοφάγου. Όπως στους ενήλικες, έτσι και στα παιδιά εκδηλώνεται με δυσφαγία, αναγωγές και πόνο στο στήθος. Η διάγνωση της ΑΟ βασίζεται στην κλινική βαθμονόμηση των συμπτωμάτων με βάση το Eckardt score (ΕS), στο βαριούχο γεύμα, την ενδοσκόπηση και τη μανομετρία του κατώτερου οισοφαγικού σφιγκτήρα (Lower Esophageal Sphincter-LES). Σήμερα, για την αντιμετώπιση της ΑΟ προτείνεται η λαπαροσκοπική μυοτομή κατά Heller (LHM-Laparoscopic Heller Myotomy) και η δια του στόματος ενδοσκοπική μυοτομή (POEM-Per Oral Endoscopic Myotomy). Η παρούσα συστηματική ανασκόπηση και μετά-ανάλυση έχει σκοπό να συγκρίνει τις δύο αυτές μεθόδους όσον αφορά την αποτελεσματικότητα και ασφάλεια τους. Υλικό-Μέθοδος. Πραγματοποιήσαμε μια συστηματική έρευνα στις ηλεκτρονικές πλατφόρμες PubMed, Google Scholar και Web of Science για κλινικές μελέτες αναφερόμενες στις δύο αυτές μεθόδους, στην αγγλική γλώσσα. Κύριες παράμετροι ενδιαφέροντος της μετά-ανάλυσης ήταν το ES και η πίεση του LES πριν και μετά την επέμβαση. Δευτερεύουσες παράμετροι ενδιαφέροντος ήταν: οι διεγχειρητικές επιπλοκές, οι μετατροπές των μεθόδων, η παρουσία γαστροοισοφαγικής παλινδρόμησης (ΓΟΠ) μετεγχειρητικά, η μέθοδος επανεπέμβασης, η επιτυχία της κάθε μεθόδου και η θνητότητα. Αποτελέσματα. Συνολικά ανευρέθηκαν 32 άρθρα που αφορούσαν 800 παιδιά (κορίτσια 345, αγόρια/κορίτσια: 1:0.73) με εύρος ηλικίας 1-17 έτη. Σε LHM υποβλήθηκαν 293 παιδιά και σε POEM 507. Λόγω έλλειψης δεδομένων όσον αφορά το ES και την πίεση του LES πριν και μετά την επέμβαση των ασθενών που υπεβλήθησαν σε LHM, η μετά-ανάλυση περιορίσθηκε στα αποτελέσματα του ES και της πίεσης του LES της POEM. Σύμφωνα με τα αποτελέσματα, στατιστικά σημαντική διαφορά παρατηρήθηκε στη μέση τιμή του ES και της πίεσης του LES πριν και μετά την επέμβαση (p<0.001 και p<0.001 αντίστοιχα). Όσον αφορά τις δευτερεύουσες παραμέτρους, από τα διαθέσιμα δεδομένα δεν προέκυψαν στατιστικά σημαντικές διαφορές μεταξύ LHM και POEM όσον αφορά τις διεγχειρητικές επιπλοκές, τις μετατροπές, τη μετεγχειρητική ΓΟΠ, τις επανεπεμβάσεις και τα ποσοστά επιτυχίας της κάθε μεθόδου (p=0.139, p=0.118, p=0.125, p=0.50 και p=0.53 αντίστοιχα). Δεν αναφέρεται θάνατος ασθενούς και στις δύο μεθόδους. Συμπεράσματα. Τα αποτελέσματα της μετά-ανάλυσης έδειξαν ότι η POEM επιτυγχάνει σημαντική βελτίωση του ES και της πίεσης του LES. Η σύγκριση μεταξύ των δύο μεθόδων λόγω έλλειψης δεδομένων δεν έγινε δυνατόν να ολοκληρωθεί με αποτέλεσμα να περιορισθούμε μόνο στα αποτελέσματα της POEM που έδειξαν ότι η τεχνική είναι αποτελεσματική και με μακροχρόνια θεραπευτικά αποτελέσματα. Αμφότερες οι μέθοδοι δεν είχαν στατιστικά σημαντικές διαφορές όσον αφορά τις διεγχειρητικές επιπλοκές, τις μετατροπές, την μετεγχειρητική ΓΟΠ, τις επανεπεμβάσεις και τα ποσοστά επιτυχίας. Απαιτούνται καλά σχεδιασμένες μελέτες στο μέλλον που θα αναδείξουν τις διαφορές, αν υπάρχουν, μεταξύ των δύο μεθόδων.Introduction. Achalasia of the esophagus (AO) is a rare motility disorder in children. Similarly, to the disease found in adults, children experience symptoms of dysphagia, regurgitation, and chest pain. Standard diagnostic approaches include barium meal, upper endoscopy, and esophageal manometry. Current available data suggest laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) as the best treatment modalities. This systematic review and meta-analysis aim to compare the safety and efficacy of LHM and POEM for AO. Methods. A systematic electronic literature search was performed in PubMed/Medline, Google Scholar and Web of Science for original articles comparing LHM and POEM limited to English texts full articles. After a detailed review, all articles collected were analyzed further in depth with respect to treatment protocols, Primary outcomes included pre- and post-Eckardt score (ES) and pre- and postoperative lower esophageal sphincter (LES) pressure. Secondary outcomes included intraoperative complications, conversions, re-interventions and type, gastroesophageal reflux (GER), success ratea, and mortality. Results. A total of 32 articles reporting on 800 patients were selected, tabulated and reviewed. There were 800 children (female: 345, M/F: 1:0.73), aging 1-17 years. LHM underwent 293 patients, and POEM 507. The meta-analysis due to missing diagnostic values of ES and LES in the LHM group was limited to the POEM results. According to the random effects model the mean ES difference pre- and pos-operatively was 4.387 (95% C.I.: 3.799-4.974), significantly different to zero (z=14.64, p<0.001), while the mean LES pressure difference pre- and postoperatively was 3.63 (95% C.I.: 2247-3.879), significantly different to zero (z=7.36, p<0.001). Moreover, our results showed no statistical differences regarding intraoperative complications, conversions, post-operative GER, re-interventions and success rates (p=0.139, p=0.118, p=0.125, p=0.50 and p=0.53 respectively), while no conversions with POEM were noticed. No mortality was reported either with LHM or POEM method. Conclusions. Both LHM and POEM demonstrated similar results regarding intraoperative complications, conversions, postoperative GER, re-interventions and success rates. Moreover, no conversions were identified with POEM technique. However, our study was failed to compare the two methods regarding their impact on ES and LES, due to inappropriate design of LHM procedure. Therefore, we were limited to the POEM results that showed statistically better outcomes regarding ES and LES pressure pre-and postoperatively. These results showed that POEM is effective and durable for treating AO in children. Well-designed studies are warranted in the future to further clarify differences between the two methods

Hernias, aortic surgery and review of the literature of incisional hernias

Ciljevi: Ispitivanje veze između incizijske hernije i operacije abdominalne aorte te općenito proučiti preporuke za prevenciju incizijske hernije. Metode: Provedena je opsežna potraga u Pub-Medu. Koristili smo sljedeće MeSH uvjete; aneurizma abdominalne aorte; incizijska hernija; ingvinalna hernija; incizijska hernija i radiologija, zatvaranje abdominalnih rana, također je korištena „snow-falling“ potraga s navedenim ključnim riječima. Rezultati: Do danas ne postoji jednoglasnost u pogledu odnosa aorte i aortoilijačne patologije te incizijske ili ingvinalne hernije, iako većina studija ukazuje na to da je moguće povećanje učestalosti incizijske hernije nakon operacije na aorti. Zaključak: Kako bismo smanjili mogućnost pojave incizijske hernije, dužina šava u odnosu da dužinu rane morala bi biti više od 4:1. Šavove treba vezati bez pretjeranog zatezivanja te za šivanje treba koristiti materijal koji upija sporo ili ne upija uopće. Koristite šav USP 2/0 na maloj igli. Kao mjesto uboda odaberite aponeurozu samo 5 do 8 mm od ruba rane, u razmaku 4 do 5 mm.Objectives: To study the relation of incisional hernias after abdominal aortic surgery and to study the recommendations for prevention of incisional hernias in general. Methods: An extensive search in Pub-Med was conducted. We used the following MeSH terms; abdominal aortic aneurysm; incisional hernia; inguinal hernia; incisional hernia and radiology, abdominal wound closure, we also did a “snow-falling” search with the above terms. Results: Still today there is not unanimity concerning the relation of aortic or aortoiliac pathology and incisional or inguinal hernias although the majority of studies suggest that there is a possible increase in the prevalence of incisional hernias after aortic surgery. Conclusions: In order to lessen the possibilities of incisional hernias suture length to wound length ration should be more that 4:1. Sutures should be tied without excessive tension and to use either a slowly absorbable or nonabsorbable suture material. Use a suture USP 2/0 mounted on a small needle. Place stitches in the aponeurosis only and 5 to 8mm from the wound edge and 4 to 5 mm apart

Acute Appendicitis: After Correct Diagnosis Conservative Treatment or Surgery?

Acute appendicitis is the most common surgical disease presented in ED. Ongoing evidence in the literature, in the last 20 years, shows a lot of benefits in favor of conservative treatment. Despite that conservative treatment does not gain the correct position at the daily practice up to day. A large number of parameters related to acute appendicitis, present diversity in their appearance, so the final estimation of the disease may by unclear and the decision for treatment may be incorrect. We analyze these parameters, aiming to clarify their role in correct diagnosis and decision making on appropriate treatment. In the present study a review of the literature is performed, regarding the etiology, pathology, clinical presentation, laboratory, and imaging data of acute appendicitis. The collection and correct estimation of these parameters, is the key for the correct diagnosis of acute appendicitis. Complicated or uncomplicated cases should be diagnosed preoperatively. The next step is the appropriate treatment, conservative or by surgery. At the present time, excluding generalized peritonitis and sepsis, the majority of patients with uncomplicated acute appendicitis and selected complicated cases can by treated successfully by conservative treatment. The majority of patients do not benefit from appendectomy

Sciatic lateral popliteal block with clonidine alone or clonidine plus 0.2% ropivacaine: effect on the intra-and postoperative analgesia for lower extremity surgery in children: a randomized prospective controlled study

<p>Abstract</p> <p>Background</p> <p>The effect of adding clonidine to local anesthetics for nerve or plexus blocks remains unclear. Most of the studies in adults have demonstrated the positive effects of clonidine on intra- and postoperative analgesia when used as an adjunctive agent or in some cases as a single to regional techniques. In the pediatric population, there are only few trials involving clonidine as an adjunct to regional anesthesia, and the analgesic benefits are not definite in this group of patients. The evidence concerning perineural administration of clonidine is so far inconclusive in children, as different types and volume of local anesthetic agents have been used in these studies. Moreover, the efficacy of regional anesthesia is largely affected by the operator's technique, accuracy and severity of operation.</p> <p>Methods</p> <p>The use of clonidine alone or combined with 0.2% ropivacaine for effective analgesia after mild to moderate painful foot surgery was assessed in 66 children, after combined sciatic lateral popliteal block (SLPB) plus femoral block. The patients were randomly assigned into three groups to receive placebo, clonidine, and clonidine plus ropivacaine. Time to first analgesic request in the groups was analyzed by using Kaplan-Meier and the log-rank test (mean time, median time, 95% CI).</p> <p>Results</p> <p>In our study, clonidine administered alone in the SLPB seems promising, maintaining intraoperatively the hemodynamic parameters SAP, DAP, HR to the lower normal values so that no patient needed nalbuphine under 0.6 MAC sevoflurane anesthesia, and postoperatively without analgesic request for a median time of 6 hours. In addition, clonidine administered as adjuvant enhances ropivacaine's analgesic effect for the first postoperative day in the majority of children (p = 0.001). Clonidine and clonidine plus ropivacaine groups also didn’t demonstrate PONV, motor blockade, and moreover, the parents of children expressed their satisfaction with the excellent perioperative management of their children, with satisfaction score 9.74 ± 0.45 and 9.73 ± 0.70 respectively. On the contrary all the patients in the control group required rescue nalbuphine in the recovery room, and postoperatively, along with high incidence of PONV, and the parents of children reported a low satisfaction score (7.50 ± 0.70).</p> <p>Conclusions</p> <p>Clonidine appears promising more as an adjuvant in 0.2% ropivacaine and less than alone in the SLPB plus femoral block in children undergoing mild to moderate painful foot surgery, with no side effects.</p> <p>Trial registration</p> <p>ClinicalTrials.gov, <a href="http://www.controlled-trials.com/ISRCTN90832436">ISRCTN90832436</a>, (ref: CCT-NAPN-20886).</p

Oral squamous cell cancer: early detection and the role of alcohol and smoking

Objective: Oral squamous cell carcinoma has a remarkable incidence worldwide and a fairly onerous prognosis, encouraging further research on factors that might modify disease outcome. Data sources: A web-based search for all types of articles published was initiated using Medline/Pub Med, with the key words such as oral cancer, alcohol consumption, genetic polymorphisms, tobacco smoking and prevention. The search was restricted to articles published in English, with no publication date restriction (last update 2010). Review Methods: In this review article, we approach the factors for a cytologic diagnosis during OSCC development and the markers used in modern diagnostic technologies as well. We also reviewed available studies of the combined effects of alcohol drinking and genetic polymorphisms on alcohol-related cancer risk. Results: The interaction of smoking and alcohol significantly increases the risk for aero-digestive cancers. The interaction between smoking and alcohol consumption seems to be responsible for a significant amount of disease. Conclusion: Published scientific data show promising pathways for the future development of more effective prognosis. There is a clear need for new prognostic indicators, which could be used in diagnostics and, therefore a better selection of the most effective treatment can be achieved

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge.

The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients

Recognizing and Managing Pancreaticopleural Fistulas in Children

Background: Pancreaticopleural fistula, an abnormal communication between the pancreas and the pleural cavity, is a rare complication of pancreatic disease in children and is mainly associated with acute pancreatitis, chronic pancreatitis, trauma or iatrogenicinjury. The present review presents the current available data concerning the pathogenesis, clinical features, diagnosis and management of this unusual but difficult clinical problem among children, in order to shed light on its pathologic manifestation and raise clinical suspicion. Methods: The review of the literature was performed through a PubMed search of pediatric original articles and case reports, using the key words “pancreaticopleural fistula”, “pancreatitis”, “pleural effusion”, “pseudocyst” and “children”. The literature search revealed 47 cases of pediatric patients with pancreaticopleural fistula. Results: Diagnosis is based on the patient’s medical history, physical examination and imaging, while the cornerstone of diagnosis is the presence of high pleural effusion amylase levels. The management of this disorder includes conservative, endoscopic and surgical treatment options. If treated promptly and properly, this clinical entity could have a lower rate of complications. Conclusions: The incidence of pancreaticopleural fistula in children may be underestimated in the literature, due to a reduced degree of clinical suspicion. A more heightened awareness of this entity is needed to improve the quality of life in children that suffer from this condition, as early diagnosis is essential for effective treatment and improved outcome