ABSTRACT BACKGROUND: Bishop-Koop ileostomy has been widely used in pediatric patients with the intention of including as much bowel as possible in the intestinal transit early in the management of children with meconium ileus and intestinal atresia. In recent years, we have been using it as an alternative to test the distal bowel function before closure of a previously constructed ostomy in selected children with questionable distal bowel motility. AIMS: The aim of this study was to present our experience with this alternative use of the Bishop-Koop ostomy. METHODS: This is a cross-sectional retrospective review of hospital records, combined with a comprehensive literature review. RESULTS: Seven children were included: five had suspected aganglionosis, one had gastroschisis complicated with ileal atresia, and one had a colonic stricture secondary to necrotizing enterocolitis. In this short series of patients, motility of the distal bowel was correctly assessed in six patients and partially correctly assessed in one patient. One patient did not pass stools per anus after the Bishop-Koop, and he was later confirmed to have Hirschsprung disease. Four patients resumed normal evacuation pattern after closure of the Bishop-Koop. One patient had a Bishop-Koop colostomy because of recurrent enterocolitis after a transanal pull-through. Although he evacuated normally while having the colostomy, the diarrhea recurred after the ostomy was closed. An additional patient, with a severe behavioral problem, did not evacuate per anus after her colostomy was transformed in a Bishop-Koop-type ostomy, despite the apparent presence of normal ganglia in the bowel wall. CONCLUSIONS: Data from the present series allow us to affirm that Bishop-Koop-type ostomy is a safe and efficient procedure that can be used to assess distal bowel function before a definitive transit reconstruction, in children with uncertain motility issues.

RESUMO RACIONAL: A ileostomia Bishop-Koop foi amplamente utilizada em pacientes pediátricos com a intenção de incluir o máximo de intestino possível no trânsito intestinal no manejo inicial de recém-nascidos com íleo meconial e atresia intestinal. Nos últimos anos, temos usado-a como alternativa para testar a função intestinal distal antes do fechamento de uma ostomia, em algumas crianças com motilidade intestinal distal questionável. OBJETIVOS: Apresentar nossa experiência com este uso alternativo da ostomia Bishop-Koop. MÉTODOS: Revisão retrospectiva dos registros hospitalares, combinada com uma revisão abrangente da literatura. RESULTADOS: Sete crianças foram incluídas: cinco tinham suspeita de aganglionose, uma tinha gastrosquise complicada com atresia ileal e uma tinha estenose de colon secundária à NEC. Nesta pequena série de pacientes, a motilidade do intestino distal foi corretamente avaliada em 6 pacientes e parcialmente avaliada em um. Um paciente não evacuou por ânus após o Bishop-Koop e mais tarde foi confirmado que ele tinha doença de Hirschsprung. Seis pacientes retomaram o padrão normal de evacuação após o fechamento do Bishop-Koop. Um paciente que fez uma colostomia Bishop-Koop por causa de enterocolite recorrente após um abaixamento transanal, recidivou a enterocolite após o fechamento definitivo. CONCLUSÕES: A ostomia tipo Bishop-Koop é um procedimento seguro e eficaz que pode ser utilizado para avaliar a função intestinal distal antes de uma reconstrução definitiva do trânsito em crianças com problemas de motilidade intestinal.

ABSTRACT Introduction: in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. Methods: retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. Results: only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. Conclusion: the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

RESUMO Introdução: no Brasil, o trauma é responsável por 40% dos óbitos na faixa etária entre 5 e 9 anos, e 18% entre 1 e 4 anos, e o sangramento é a principal causa de prevenção morte na criança traumatizada. O manejo conservador de trauma abdominal contuso com lesão de órgãos sólidos - iniciado na década de 60 - é a tendência mundial atual, com estudos mostrando taxas de sobrevivência acima de 90%. O objetivo do presente trabalho foi avaliar a eficácia e segurança do tratamento conservador em crianças com trauma abdominal contuso tratado no Hospital das Clínicas da Universidade de Campinas, nos últimos cinco anos. Métodos: análise retrospectiva de prontuários de pacientes classificados por níveis de gravidade da lesão, em 27 crianças. Resultados: apenas uma criança foi submetida a cirurgia por falha inicial do tratamento conservador (instabilidade hemodinâmica persistente), resultando em uma taxa de sucesso global de 96% do tratamento conservador inicial. Outras cinco crianças (22%) desenvolveram complicações tardias que exigiram cirurgias eletivas: lesão na bexiga, dois casos de coleção perirenal infectada (secundária à lesão de sistema de coleta renal), um pseudocisto pancreático e um cisto esplênico. Resolução da complicação foi atingida em todas as crianças, com preservação anatômica e funcional do órgão afetado. Não houve mortes nesta série. Conclusão: a abordagem inicial conservadora no tratamento de trauma abdominal contundente foi eficaz e segura com alta resolução e baixa taxa de complicações levando a uma alta taxa de preservação dos órgãos afetados. Nível de evidência III - estudo prognóstico e terapêutico.

SUMMARY A gonadal tumor was diagnosed in the first months of life in a patient with genital ambiguity, a 45,X/46,XY karyotype, and mixed gonadal dysgenesis. Gonadal biopsies at the age of 3 months revealed dysgenetic testes and a gonadoblastoma on the right testis. Even though gonadal tumors are rare in childhood, this case indicates that prophylactic removal of dysgenetic gonads should be performed as early as possible, especially when the female sex is assigned to a patient with a Y-chromosome sequence.

Resumo Objetivo: Descrever o caso de um lactente portador de doença de Hirschsprung na forma aganglionose colônica total que, após a ressecção cirúrgica do segmento agangliônico, manteve quadro irreversível de obstrução intestinal funcional; discutir as dificuldades no manejo dessa forma da aganglionose congênita e apontar um mecanismo patogenético plausível para o caso. Descrição do caso: O diagnóstico de doença de Hirschsprung na forma aganglionose colônica total foi definido em lactente aos dois meses de vida, após episódio de enterocolite, choque hipovolêmico e desnutrição grave. Após ressecção colônica, o paciente não recuperou a função motora intestinal que possibilitasse a alimentação via enteral. O exame do íleo remanescente pós-operatório mostrou presença de plexos ganglionares e redução numérica das células intersticiais de Cajal em segmentos proximais do intestino. Aos 12 meses de vida, o paciente mantém-se dependente de nutrição parenteral total. Comentários: A doença de Hirschsprung na forma aganglionose colônica total tem particularidades clínico-cirúrgicas que a diferenciam das formas clássicas e dificultam o diagnóstico e o manejo clínico-cirúrgico. A evolução pós-operatória pode associar-se à morbidade permanente decorrente de dismotilidade intestinal. A redução numérica ou as alterações das conexões neurais das células intersticiais de Cajal podem representar uma possível base fisiopatológica para a condição.

Abstract Objective: To describe the case of an infant with Hirschsprung's disease presenting as total colonic aganglionosis, which, after surgical resection of the aganglionic segment persisted with irreversible functional intestinal obstruction; discuss the difficulties in managing this form of congenital aganglionosis and discuss a plausible pathogenetic mechanism for this case. Case description: The diagnosis of Hirschsprung's disease presenting as total colonic aganglionosis was established in a two-month-old infant, after an episode of enterocolitis, hypovolemic shock and severe malnutrition. After colonic resection, the patient did not recover intestinal motor function that would allow enteral feeding. Postoperative examination of remnant ileum showed the presence of ganglionic plexus and a reduced number of interstitial cells of Cajal in the proximal bowel segments. At 12 months, the patient remains dependent on total parenteral nutrition. Comments: Hirschsprung's disease presenting as total colonic aganglionosis has clinical and surgical characteristics that differentiate it from the classic forms, complicating the diagnosis and the clinical and surgical management. The postoperative course may be associated with permanent morbidity due to intestinal dysmotility. The numerical reduction or alteration of neural connections in the interstitial cells of Cajal may represent a possible physiopathological basis for the condition.

PURPOSE: To assess the efficacy of an adjustable inspiratory occlusion valve in experimental bronchopleural fistula during mechanical ventilation.METHODS:We studied six mechanically ventilated pigs in a surgically created, reproducible model of bronchopleural fistula managed with mechanical ventilation and water-sealed thoracic drainage. An adjustable inspiratory occlusion valve was placed between the thoracic drain and the endotracheal tube. Hemodynamic data, capnography and blood gases were recorded before and after the creation of the bronchopleural fistula as well as after every adjustment of the inspiratory occlusion valve.RESULTS:When compared with the standard water-sealed drainage treatment, the use of an adjustable inspiratory occlusion valve improved the alveolar tidal volume and reduced bronchopleural air leak (p<0.001), without hemodynamic compromise when compared with conventional water sealed drainage.CONCLUSION: The use of an adjustable inspiratory occlusion valve improved the alveolar tidal volume, reduced alveolar leak, in an experimental reproducible model of bronchopleural fistula, without causing any hemodynamic derangements when compared with conventional water sealed drainage.

PURPOSE:To investigate the hemodynamic and ventilatory changes associated with the creation of an experimental bronchopleural fistula (BPF) treated by mechanical ventilation and thoracic drainage with or without a water seal.METHODS :Six large white pigs weighing 25 kg each which, after general anesthesia, underwent endotracheal intubation (6mm), and mechanically ventilation. Through a left thoracotomy, a resection of the lingula was performed in order to create a BPF with an output exceeding 50% of the inspired volume. The chest cavity was closed and drained into the water sealed system for initial observation of the high output BPF.RESULTS:Significant reduction in BPF output and PaCO2 was related after insertion of a water-sealed thoracic drain, p< 0.05.CONCLUSION: Insertion of a water-sealed thoracic drain resulted in reduction in bronchopleural fistula output and better CO2 clearance without any drop in cardiac output or significant changes in mean arterial pressure.

Flexible endoscopes are fundamental in various medical specialities; in general they are heat-sensitive, semi-critical, and subject to high level disinfection. Glutaraldehyde is largely used for this purpose, due to its high compatibility and low-cost. However, its tolerance of mycobacteria and occupational toxicity lead to pressure being applied for the adoption of alternative germicides. A systematic review was undertaken aiming to seek evidence regarding the effectiveness, toxicity and potential harm caused to the endoscopes by those germicides which are alternative to glutaraldehyde and which are available on the market in Brazil. A total of 822 publications was identified in 13 electronic databases, between 2008 and 2013. Of these, 23 studies were selected, considering the best quality of evidence available. The publications point to the superiority of peracetic acid and of orthophthaldehyde regarding efficacy in high level disinfection. Only orthophthaldehyde presented an adverse event clearly related to its use. There is insufficient evidence to assert that any of these germicides has greater potential for harm to the equipment.

Fundamentales en diversas especialidades médicas, los endoscopios flexibles son, normalmente, termosensibles, semicríticos y sometidos a la desinfección de alto nivel. El glutaraldehído es muy utilizado para esa finalidad, en razón de la gran compatibilidad y bajo custo, pero la tolerancia de microbacterias y el hecho de ser o no tóxico de modo ocupacional presionan por la adopción de germicidas alternativos. Fue realizada revisión sistemática con el objetivo de buscar evidencias sobre la efectividad, toxicidad y potenciales daños causados a los endoscopios por los germicidas alternativos al glutaraldehído, disponibles en el mercado brasileño. Fueron identificadas, en 13 bases electrónicas, 822 publicaciones, entre 2008 y 2013. De estas, fueron seleccionados 23 estudios, considerando la mejor cualidad de evidencia disponible. Las publicaciones apuntaron para la superioridad del ácido peracético y del ortoftalaldehído cuanto a la eficacia en la desinfección de alto nivel. Solamente el ortoftalaldehído presentó evento adverso claramente relacionado a su utilización. No hay evidencias suficientes para afirmar que algun de estes germicidas presenta mayor potencial de daños a los equipos.

Endoscópios flexíveis são fundamentais em diversas especialidades médicas; em geral são termossensíveis, semicríticos e submetidos à desinfecção de alto nível. O glutaraldeído é largamente utilizado para este fim, devido à alta compatibilidade e baixo custo, porém, a tolerância de micobactérias e a toxicidade ocupacional pressionam por adoção de germicidas alternativos. Foi realizada revisão sistemática com objetivo de buscar evidências sobre a efetividade, toxicidade e potenciais danos causados aos endoscópios pelos germicidas, alternativos ao glutaraldeído, disponíveis no mercado brasileiro. Foram identificadas, em 13 bases eletrônicas, 822 publicações, entre 2008 e 2013. Destas, foram selecionados 23 estudos, considerando a melhor qualidade de evidência disponível. As publicações apontaram para a superioridade do ácido peracético e do ortoftalaldeído quanto à eficácia na desinfecção de alto nível. Somente o ortoftalaldeído apresentou evento adverso claramente relacionado à sua utilização. Não há evidências suficientes para afirmar que algum destes germicidas possui maior potencial de danos aos equipamentos.

INTRODUCTION: Correction of gastroschisis can be accomplished by primary or staged closure. There is, however, no consensus regarding the best approach or criteria to favor one method over the other has been established. OBJECTIVE: To compare the outcome of primary and staged closure in newborns with gastroschisis using intravesical pressure (IVP) as the decision criterion. PATIENTS & METHODS: We prospectively analyzed 45 newborns with gastroschisis. An IVP with a threshold of 20 cm H2O was used to indicate primary or staged closure, and the outcomes between the two methods were compared. RESULTS AND DISCUSSION: Newborns in whom primary closure was feasible were born at a lower gestational age. There was no significant difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay. Compared with previous reports, our data showed higher rates of prenatal diagnosis and cesarean delivery, a lower average birth weight, a higher rate of small gestational age babies and a more frequent association with intestinal atresia. Conversely, our data showed a lower rate of postoperative necrotizing enterocolitis and a lower average length of hospital stay. CONCLUSION: No significant difference was observed in the outcome of newborns who underwent primary closure or staged closure of gastroschisis when using an IVP below 20 cm H2O as the criterion for primary closure.

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4¡6.7 mEq/L, and the mean serum albumin level was 2.35¡0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

OBJETIVO: Avaliar a evolução clínica e comparar a eficácia do tratamento fisioterapêutico intensivo ou mínimo, em neonatos e lactentes com torcicolo congênito. MÉTODOS: Foram atendidas no Ambulatório de Fisioterapia e Cirurgia Pediátrica do Hospital de Clínicas da Universidade Estadual de Campinas 47 crianças com torcicolo congênito. Analisaram-se, retrospectivamente, antecedentes maternos, neonatais, apresentação clínica e tratamento fisioterapêutico, classificado de acordo com a freqüência das sessões. O tratamento intensivo foi definido como sessões de fisioterapia realizadas pelo fisioterapeuta no ambulatório, acrescidas de exercícios diários realizados pelos pais em domicílio. O tratamento mínimo foi considerado quando apenas o fisioterapeuta realizava as sessões semanalmente no ambulatório, sem a participação dos pais. RESULTADOS: Quanto às características demográficas da população, observou-se: idade média materna=26 anos; parto normal=40 (85%); mães primigestas=35 (75%); idade média ao diagnóstico=50 dias. A presença de nódulo intramuscular foi notada em 46 (98%) pacientes. As seguintes doenças estiveram associadas: luxação congênita de quadril igual=4 (8%); fratura de clavícula=2 (4%); pé torto congênito=1 (2%). O tratamento intensivo foi realizado em 34 (72%) pacientes e a cura observada em 100%, após 74 dias, em média. O tratamento mínimo foi aplicado em 13 (28%) pacientes e a cura observada em dez (77%), tratados em média por 130 dias. CONCLUSÕES: O torcicolo congênito apresentou evolução clínica favorável em ambos os grupos. O tratamento intensivo propiciou maior índice de cura em menor tempo de tratamento.

OBJECTIVE: To evaluate the clinical course and to compare the effectiveness of physiotherapeutic treatment performed daily or once a week in newborns and infants with congenital torticollis. METHODS: 47 patients with congenital torticollis were assisted at the Physiotherapy and Pediatric Surgery Services of the Clinical Hospital of Campinas University. The following data were retrospectively collected: maternal and neonatal history, clinical presentation and physiotherapeutic treatment classified according to the frequency of the exercises. Intensive treatment was defined as sessions performed at the daycare clinic by the physiotherapist plus daily sessions performed by parents at home. Minimal treatment was defined as weekly sessions performed only by the physiotherapist at the daycare clinic, without participation of the parents. RESULTS: The demographic characteristics of the studied patients were: mean maternal age=26 years; first gestation=35 (75%); vaginal delivery=40 (85%); mean age at diagnosis =50 days. A sternomastoid nodule was felt seen in 46 (98%) patients. Diseases associated with congenital torticollis were: congenital hip dislocation=4 (8%); fracture of clavicles=2 (4%); and club feet=1 (2%). Intensive treatment was performed in 34 (72%) patients for an average of 74 days and the cure was achieved in 100%. Minimal treatment was performed in 13 (28%) for an average of 130 days and ten (77%) patients achieved cure. CONCLUSIONS: Congenital torticollis had favorable outcome in both groups. The intensive treatment was followed by higher rates of cure in smaller period of time.

OBJETIVO: Avaliar o valor prognóstico da distensão de alças intestinais observada em radiografias na evolução e mortalidade de neonatos com enterocolite necrosante. MATERIAIS E MÉTODOS: Nas radiografias de abdome de 53 pacientes obtidas no momento da suspeita diagnóstica de enterocolite necrosante, foi realizada a medida do diâmetro da alça mais distendida (AD), assim como a distância entre a borda superior da primeira vértebra lombar e a borda inferior da segunda (L1-L2), a distância entre as bordas laterais dos pedículos da primeira vértebra lombar (L1), e foram estabelecidas as associações entre AD/L1-L2 e AD/L1. Esta medida foi considerada como possível determinante de potenciais complicações, intervenção cirúrgica e mortalidade. RESULTADOS: Os pacientes que necessitaram de tratamento cirúrgico, aqueles que tiveram complicações durante a evolução e aqueles que morreram da doença tiveram a relação entre AD e AD/L1-L2 maiores (p < 0,05). Os valores de AD/L1 e a localização da alça mais distendida não foram diferentes nos grupos com evolução desfavorável. CONCLUSÃO: Distensão de alça intestinal detectada em radiografias de abdome realizadas na admissão sugerem pior prognóstico em enterocolite necrosante. Outrossim, medidas do diâmetro da alça mais distendida nessas radiografias são um método simples e reprodutível que oferece informações diagnósticas e prognósticas.

OBJECTIVE: To evaluate the prognostic value of bowel loops dilatation as a finding on radiographs in the development and mortality of neonates with necrotizing enterocolitis. MATERIALS AND METHODS: On abdominal radiographs of 53 patients for diagnostic suspicion of necrotizing enterocolitis, the major diameters of dilated bowel loops (AD) were measured, as well as the distance between the upper border of the first lumbar vertebra and the lower border of the second one (L1-L2), and the distance between the lateral borders of the first lumbar vertebra (L1) pedicles, and the subsequent association between AD/L1-L2, AD/L1. This measure was considered as a possible determining factor for potential complications, surgical intervention and mortality. RESULTS: The patients who needed surgical management and who had complications during progression and died of the disease had showed increased AD and AD/L1-L2 (p < 0.05). AD/L1 values and site of the most dilated bowel loop were not different in the groups with unfavorable progression. CONCLUSION: Bowel loop dilatation detected on initial supine abdominal radiographs suggests a worst prognosis in necrotizing enterocolitis. Furthermore, measurement of the most dilated bowel loop on these radiographs is a simple and reproducible method that adds diagnostic and prognostic information.

OBJETIVO: Relatar a experiência inicial do Centro Infantil Boldrini com a esplenectomia laparoscópica (EL) em crianças e adultos jovens. MÉTODO: Foram revisados os prontuários de 40 pacientes (mediana da idade de 6,6 anos; 1 a 22,8) submetidos à EL entre Julho de 2000 e Maio de 2002. As principais indicações de acordo com a doença de base foram: doença falciforme (DF) em 20 pacientes (50%), esferocitose hereditária em 10 (25 %), púrpura trombocitopência idiopática em oito (20 %), doença de Hodgkin em um e anemia hemolítica a esclarecer em um. RESULTADOS: Trinta e oito esplenectomias foram completadas por via laparoscópica (duas conversões) e em doze foi realizada adicionalmente a colecistectomia. A mediana do tempo operatório foi de 127,5 minutos (90-240 min) e sete (17,5 %) baços acessórios foram encontrados. Sangramento intra-operatório foi significativo apenas nas duas conversões, mas não houve necessidade de transfusões. A mediana do peso dos baços foi de 250 g (106-1000; n=36). Complicações pós-operatórias ocorreram em sete (17,5 %) pacientes e, nos portadores de DF, 35% desenvolveram síndrome torácica aguda. A mediana da permanência hospitalar pós-operatória foi de dois dias (2 - 14). O seguimento variou de 23 dias a dois anos (mediana de 11 meses). CONCLUSÕES: A EL pode ser realizada de modo seguro mesmo em baços de grande tamanho e é opção atrativa que pode substituir o procedimento aberto. Em pacientes com DF, a taxa de complicações permanece alta, sugerindo mecanismos outros que vão além da escolha da via de acesso cirúrgica.

BACKGROUND: Laparoscopic splenectomy (LS) is becoming the procedure of choice in the treatment of children with hematological disorders. However, concerns remains regarding conversion rates, dissection and extraction of the spleen. The authors analyze their early experience at Boldrini's Children Cancer Center-Brazil in 40 LS performed in children and young adults. METHODS: Retrospective review of the charts of 40 patients (median age of 6.6 years; range 1 to 22.8) who underwent LS, between July/ 2000 and May/ 2002. The main indications were sickle cell disease (SCD) (20 - 50 %), hereditary spherocytosis (10 - 25 %) and idiopathic thrombocytopenic purpura (8 - 20 %). RESULTS: All but two splenectomies were performed exclusively by laparoscopy, and 12 patients also underwent a concomitant cholecystectomy. The mean operating time was 127.5 minutes (90-240m). In seven patients (17.5%) accessory spleens were found and removed. Intraoperative bleeding was significant only in the two cases that required conversion to an open procedure, although no transfusion was needed. The median weight of the spleen was 250 g (range 106g-1000g; n=36). Complications were observed in seven patients (17.5 %) with SCD that developed acute chest syndrome. There were no deaths in this series and the median postoperative stay at the hospital was two days (2 - 14). Follow-up ranged from 23 days to two years. CONCLUSIONS: On the basis of our experience, LS is a safe procedure, even to treat large spleens and became an attractive option that might replace the open procedure. In SCD patients, the rate of complications remains high, suggesting mechanisms other than the scope of the choice of surgical approach.

OBJETIVO: Com a introdução e o aprimoramento de técnicas para a realização de fístulas arteriovenosas (FAV) em crianças, pacientes renais crônicos puderam iniciar tratamento com hemodiálise sem a necessidade de uso de shunts externos. MÉTODOS: Com o objetivo avaliar os resultados da confecção de fístulas arteriovenosas em crianças e adultos jovens de baixo peso e os fatores de risco relacionados. Foram levantados retrospectivamente os prontuários de 31 pacientes submetidos a 35 FAV, com idade variando de cinco a 24 anos, com peso entre 16 e 50kg. Os fatores de risco estudados foram hipertensão arterial, antecedentes de trombose, tendência à hipovolemia e presença de hipercolesterolemia. RESULTADOS: O índice de perda observado foi de 25% em pacientes com menos de 20kg e de 22,2% naqueles com mais de 20kg, resultados comparáveis aos da literatura. CONCLUSÕES: Observou-se que fístulas proximais não sofreram trombose; não houve relação entre a perda da FAV e os fatores de risco estudados e observou-se um índice de perda tardia de 23,5% nos pacientes que não estavam sendo submetidos à hemodiálise. Nos pacientes que utilizavam a FAV não se observou perda da mesma.

BACKGROUND: Since the development of operative techniques for arteriovenous fistula (AVF) creation, chronic hemodialysis for treatment of end-stage renal disease in children and young adults became an actual therapeutic option, obviating the need for external shunts. PURPOSE: To report our experience with surgically created AVF in 31 patients, aged 5 to 24 years old, relating long-term fistula patency with risk factors such as arterial hypertension, previous thrombosis events, tendency to hypovolemy, hypercholesterolemy, vein caliber and routine use of the fistula. RESULTS: Overall rate of fistula thrombosis was 22,8%, being 25% in patients weighing less than 20kg and 22,2% in those over 20kg. All fistulas performed on proximal arm veins were patent after 5 to 32 months follow-up. Unused AV fistulas apparently had an increased risk of thrombosis when compared to fistulas routinelly used for hemodialysis access. None of the remainy risk factors studied showed estatistical association with loss of patency. CONCLUSION: AV fistulas can be safely performed in children with success rate comparable to those observed in older patients. Vein caliber and routine use of the fistula appears to have a strong influence on long term patency.

O presente estudo tem como objetivo analisar os métodos utilizados para o tratamento das complicações relacionadas ao cateter de diálise peritoneal , avaliando-se o uso das vias aberta e laparoscópica. Vinte pacientes apresentaram 35 complicações relacionadas ao cateter de diálise (obstrução 60%, peritonite 34,3% e infecção do trajeto 5,7%) e foram tratados cirurgicamente. Para o tratamento das complicações, foram realizados 22 procedimentos por via aberta (laparotomia) e 13 por via laparoscópica. Através do método laparoscópico, foi possível desobstruir e manter o cateter em 80% dos cateteres obstruídos, ao passo que 100% foram trocados ou retirados quando a via aberta foi utilizada. O tempo necessário para reutilização completa do mesmo após o procedimento foi maior pelo método aberto. Os dados apresentados sugerem que a laparoscopia é um método eficaz como opção terapêutica para o tratamento das complicações relacionadas ao cateter de diálise peritoneal, pela visualização direta da cavidade peritoneal e possibilidade de reposicionamento ou desobstrução do mesmo, não sendo portanto necessária a sua troca e diminuindo também o tempo necessário para reutilização completa do cateter.

Peritoneal dialysis is a good and safe method to handle end-stage renal diseases while waiting arteriovenous fistula for hemodalysis or a renal transplantation. However, there are some catheter related complications such as obstruction and peritonitis. Those complications are usually treated by laparotomy, but with the increasing use of the minimally invasive surgery, laparoscopy became a therapeutic option. The aim of the present study is to evaluate the open vs. the laparoscopic approach in the management of the related catheter complications of peritoneal dialysis. Twenty patients developed 35 catheter related events treated surgically (obstruction 60%, peritonitis 34,3% and tunnel infection in 5,7%). The open procedure was used 22 times and the laparoscopic 13. Through laparoscopy, it was possible to remove the obstruction and keep the catheter in 80%, while when the open approach was used 100% had to be replaced or removed. Peritoneal dyalysis was restarted later in the open method. Our data suggest that laparoscopy is an effective and safe method for the management of the catheter related complications of peritoneal dialysis, allowing direct visualization and manipulation of the peritoneal cavity and decreasing of the time span until resuming full utilization of the cateter.