Dr. Chiara Oreglio - Best of the Best in Pediatric Surgery 2025

Let's start off with our first presentation, uh, Dr. Kiara Oreglio, who is from UPA, and she is from the University of Florence in Florence, Italy. So let's play the first presentation. Good afternoon, everyone. I'm Kiara Oreglia, and I would like to present you our experience with the use of bioprosthesis for chest wall reconstruction in pediatric surgical oncology. We have nothing to disclose. And as we all know, primary chest wall tumors are a rare entity in pediatric population with wingsarcoma being the most common one. The consensus exists in their management with surgery remaining the main stay of treatment being composed by two phases, a first demolitive phase and a second very important reconstructive phase, aiming at recreating chest wall anatomy. In order to do so, a wide range of options exist ranging from rigid material to non rigid material. And bearing in mind that our final goal is to reach a good oncological outcome, the material of choice must encompass features of both stiffness and malleability, being at the same time biologically compatible. Indeed, it must not only be able to physiologically integrate with the tissues, but also to cope with the ongoing growing process that our pediatric patients are undergoing. Therefore, the answer to the question which material is the best, there remain controversial and highly debated. We present you the experience of a third referral center in the use of bioprosthesis for chest walling sarcoma patients, reporting the case of the youngest patient affected by this pathology reported in literature. We decided to use a porcine a cellular derma collagen that is dermacol. And we included all patients that were treated at our institutions for chest walling sarcoma and who underwent multidisciplinary evaluation at the tumor board and the same standardized surgical technique. And a total of three patients were retrieved, two males and one female, the latter being just 18 months old at diagnosis. Here, you can see their peritive CT scans performed after the termination of the new ant chemotherapy cycles. The surgical procedure begins with the uhpy and general assessment with marking of the tumor borders through the use of transfix needles over which a thoracotomy incision is performed. We proceed with the end block removal of the lesions and the surrounding tissues that may be involved by the tumor. After that, the second reconstructive phase begins with the positioning of the prosthesis over the chest wall defect. As you can see here, bioprosthesis are very easy to manipulate and allow the surgeon to perform even the finest and most precise adjustment in order to have the mesh as tailored as possible to the patient's anatomy. Indeed, this is our ideal final result, reaching what we call the drum like tension, that is a tension strong enough to guarantee internal organ protections while accommodating with the chest wall growing process. After that, a latissimus dorsi muscular flap is created and is rotated and fixated over the prosthesis with a sparing of the toracolsar artery. And this is the final result with a variable number of chest tube being positioned from case to case. In all of our patients, we had at least three ribs removed in accordance with the oncological guidelines, and in two cases, there was diaphragmatic involvement that was removed and reconstructed again with the use of permacol. In one cases, the the defect was large enough that we had to use also two rigid rigid two rigid material bars that are the status bar. But thanks to the use of permacol, we were able to position only two of them instead of four. None of our patients reported any periopetive complications according to the Cladian classification, and an R0 was reached in all cases. Most importantly, all of our patients were able to restart chemotherapy within two months from surgery. Here are the final results and as you can see, not only the aesthetic outcome is satisfactory, but also no limitations of movements are reported by any of our patients. And she is our youngest case and uh you can see from the video that there is no paradoxical chest wall movement. The parents are quite happy with the results and uh she is obviously disease free at the follow up. In conclusion, we can say that permacol mesh presents good adaptibility to the growing process with a reduced risk of rejection and infection. At the same time, it is highly versatile for reconstruction of highly mobile tissues such as the diaphragm, and it is easy to remodel and to suture. Moreover, the thickness of the mesh can be adjusted according to the age, the region to be reconstructed and the defect side, making it feasible to use even in very young children. In conclusion, it is possible to associate it with other synthetic material in what we call then hybrid reconstruction. Thus our take home message is that we our practice should be simple and at least as least invasive as possible and we must always remember that we should dismantle illnesses without dismantling the patient's identity. So thank you very much for the opportunity and for your time. Q, thank you for that. Um, that was outstanding. Um, it's very cool stuff and when we start commenting, I know a few of us have some questions. I want to introduce one of another Cincinnati Children's colleague, Dr. Laura Galganski, who's going to be here as a panelist to discuss these topics as well. So Laura, thanks for joining us here. Um, Mira. Yes, I have questions. Go for it. This is an awesome presentation. Thank you for sharing um what you guys have been doing and all the work. Um, it really is an incredible accomplishment. I think uh my first question is really around obviously age and growth. So as kids grow and we, you know, one of the challenges obviously of pediatric surgery compared to some of the adult um practices is how do you adjust for that with the mesh and the synthetic? Do you need to go back and do a reoperation to give them the sort of drum effect um at a larger size once they get bigger or what do you expect from from reintervention? Okay, thank you very much first for having me here. It's great opportunity and thanks for this question which I find very interesting. Um, actually, with the follow up that we have on the first one is just one year more or less. And uh I don't really have an answer to your question. Well what I can tell you is that compared to very rigid structures such as the titanium bars, the strut bar, the bioprosthesis integrates with the tissue. Therefore, it's the tissue while the surrounding tissue grows, it also grows with it. So it's not like a strut bar is very rigid and it obliges the surrounding the surrounding ribs to be stick to it and then and thus it modifies the shape of the chest wall leading to what it's the most common complication after that it is scoliosis or deformation of chest wall. With bioprosthesis, we don't see that because the tissues are free to grow in their own way. Whether there will be the need or not to reintervene, we don't have any experience with that. It didn't happen and the patient that were treated with that, they did not even the oldest one did not develop any kind of difficulty in movement and also doing with the imaging, like the rib cage doesn't seem to be deformed by that. Meaning that our our our prosthesis kind of the tissue around our prosthesis evolves with them. And this integration that happens that it is proven at an histological level, does not prevent any growing or any movement, let's say of the tissue. So no, I would say no. Fantastic. Thank you so much. I really appreciate it. There are some other questions in the chat, so if you can pop over there, um maybe you can answer some of those questions online or we'll email them to you later. Yeah, Kiara, we can help you with that. Um, and and that you can either go in the in the other room and chat or we can send them to you here in the backstage chat. So. If you could send me, that would be very much appreciated because I have the other Thanks so much. Perfect. All right. Thanks. Thank you so much.