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Paediatric oncological surgery is the branch of paediatric surgery that is dedicated to the surgical treatment of paediatric oncological and haematological diseases and their complications. It is one of the basic pillars for the treatment of solid paediatric tumours.
These are illnesses that, due to their severity, complexity, and rareness, must be centralised in hospitals that are equipped with experienced multidisciplinary teams and the technology and medical experience necessary. The evolution of this unit has often gone hand-in-hand with the surgical advances achieved in solid organ transplants, which has allowed it to develop advanced techniques that now make enormously difficult cases operable. In addition, it frequently requires collaboration from other highly complex paediatric specialities (heart surgery, neurosurgery, spinal surgery, plastic surgery, etc.).
Vall d’Hebron is the hospital that offers the most oncology services in Catalonia, and it is a member of the European Reference Networks (ERNs) for Paediatric Oncology “PaedCan” and Rare Haematological Diseases “EuroBloodNet”. It is also accredited by JACIE for paediatric haematopoietic stem cell transplants.
Paediatric tumours are complex and rare. Treating them in reference centres such as Vall d’Hebron offers the maximum chances of success. The Oncology Surgery Unit is a highly specialised reference unit that works in collaboration with the Paediatric Oncohaematology Department and other related departments, to offer the patient the best possible quality of care. We boast medical, surgical, and central departments that are highly specialised in oncological care and that ensure a comprehensive vision of the process. They incorporate all of the preventative, diagnostic, therapeutic, and monitoring aspects that these patients require, including personalised therapies and the use of genomic platforms. The hospital has some of the latest technological advances at its disposal, which allows us to offer everything from minimally invasive and robotic surgery to combined treatments using interventional radiology and complex multidisciplinary interventions. The position of Vall d’Hebron Hospital as a national reference centre for paediatric solid organ transplants allows for comprehensive care in cases where transplants are the only treatment or part of the treatment (especially in liver and kidney tumours) to cure the illness.
The Unit also provides the surgical treatments necessary for benign and malignant paediatric haematological diseases and haematopoietic stem cell transplants, such as fertility preservation techniques and the removal of the spleen in some types of anaemia.
We also participate in VHIR’s Translational Research in Cancer in Children and Teenagers Group as a fundamental part of the team, which works closely with clinical care, mostly through the Programme for Personalised Medicine in Paediatric Cancer. We also collaborate with other national and international research centres, along with several international collaborative groups for solid paediatric tumours. This allows us to remain at the forefront of surgical treatment for paediatric oncohaematology patients.
Either as a unit or individually, we participate in and/or are accredited by, via external audits, the following national and international networks, which guarantee that patients can access our unit from any point within the Spanish or European healthcare system:
ERN (European Reference Networks)
Reference Centres, Services and Units (RCSU)
The Unit treats all kinds of benign and malignant tumours, both visceral and of the soft tissue (thoracic and abdominal), with the exception of tumours of the central nervous system, the locomotor apparatus, and the heart, which are operated on by other surgical departments at our centre. We cover the age range from the prenatal period to adolescence, and even treat young adults (for some types of tumours).
We treat, among others, the following solid tumours:
Among the soft-tissue sarcomas, the following are included: retroperitoneal tumours, sarcomas of the biliary tract, gynaecological sarcomas, etc. We are a reference centre in Spain for the treatment of all kinds of paediatric sarcomas, and we are part of the EpSSG Surgical Subcommittee.
In bone sarcomas, we treat tumours of the thoracic wall, even when the vertebrae and medullary canal are affected (in collaboration with the Spine Unit) and/or the case requires complex thoracic reconstruction.
Regarding haematological diseases, we would especially like to mention:
Lastly, the Oncology Surgery Unit coordinates and takes part in Vall d’Hebron Hospital Paediatric Vascular Anomalies Committee, which meets once a month. This committee is comprised of dermatologists, plastic surgeons, paediatric surgeons, radiologists, pathologists, interventional radiologists, oncologists, and paediatricians. Its objective is to diagnose and treat the most complex cases of anomalies and both cutaneous and visceral vascular tumours.
Paediatric surgery is the only medical speciality exclusively dedicated to diagnosis, treatment, and post-operative care for problems which occur during the life stage between the foetal period and adolescence and which need to be treated surgically. The surgical pathologies, physiology, doctor-patient relationship, and needs of the paediatric patient are very different from those of an adult. Due to the complexity of the pathologies treated and the special needs of the paediatric patient, this type of surgery is usually restricted to tertiary centres.
Thanks to the wide range of pathologies we treat, the paediatric surgeons here receive training on how to carry out procedures in almost all surgical areas. Working closely with obstetricians, the paediatric surgeons participate in detecting and treating pathologies that are diagnosed in utero, providing prenatal medical advice to families, and even carrying out surgeries on foetuses or during labour.
The specialists in paediatric surgery receive specific training on how to correct congenital abdominal, thoracic, and urological defects, some of which can potentially be fatal. We also provide care for patients who are multiple trauma victims and those who need surgical treatment for solid tumours. We are also the specialists who treat the urological and gynaecological problems that occur in this age range.
VHUH’s Paediatric Surgery Department is the reference centre in Catalonia for the surgical treatment of most problems in paediatric patients, and in some procedures, it is the reference centre for the entire country, covering all areas of paediatric surgery (from organ transplants to foetal surgery, and every sub-speciality in between).
In order to offer the best quality of care possible, the Department is organised into surgical sub-specialities: Neonatal Surgery, Oncological Surgery, Digestive Surgery, Thoracic Surgery, Hepatobiliopancreatic Surgery, and Urology. This innovative structure allows us to obtain a high level of specialisation and competence in each area of paediatric surgery. General surgery tasks (those corresponding to major outpatient surgery and emergency surgery) are shared among all members of the team.
Our Department was the first in the country to use foetal surgery techniques and it is part of a multidisciplinary foetal medicine programme. We are committed to performing highly complex surgery, such as oncological surgery and reconstructive urological surgery, also using minimally invasive surgery, even in newborns, and we are pioneers in foetal surgery. We also have a minimally invasive surgery simulation laboratory. Within these minimally invasive techniques, we have carried out robotic surgery since 2009; we were the first paediatric hospital in the country with a robotic surgery programme that was applied to every area of paediatric surgery.
We were also the first Paediatric Surgery Department in Spain to carry out a paediatric kidney transplant (1981) and paediatric liver transplant (1985), and we also did the first reduced-sized liver transplant (1987) and the first split liver transplant (1992). We continue to be directly involved with both transplant programmes, which have among the highest volumes of patients and the best results in the country.
In the year 2012, our Paediatric Surgery Department received the Certificate of Hospital Accreditation for Specialist Training in Paediatric Surgery, an acknowledgement from the European Board of Paediatric Surgeons that is backed by the UEMS, distinguishing it as a centre of excellence in training paediatric surgeons. We also actively participate in national and international programmes and have various RCSU (Department of Health Reference Centres, Services and Units) and ERN (European Reference Networks) accreditations.
For more than 20 years now, we have maintained several well-known lines of research in experimental paediatric surgery (and also more specifically, in foetal surgery) at the Vall d'Hebron Research Institute (VHIR). In 2015, we created the “Bioengineering, Cell Therapy and Surgery in Congenital Anomalies” group, which is currently carrying out research on the prenatal treatment of spina bifida and congenital diaphragmatic hernias. In addition, among other projects, we have carried out research projects on amniotic band syndrome, gastroschisis, oesophageal atresia, and cleft lip/palate.
As regards clinical research, our Department is constantly carrying out research activities and boasts numerous national and international publications. One noteworthy example is the first multi-centre randomised study on treating parapneumonic empyema. It compares video-assisted thoracoscopy to drainage and the use of fibrinolytics and was published in the journal Pediatrics in 2014. Another two examples are our intestinal lengthening techniques and the treatment of congenital portosystemic shunts (Abernathy malformation).
At the same time, we collaborate with other research teams, especially in the field of paediatric oncology, and we also participate in collaborative studies and international multi-centre studies.
Neonatal Surgery is the sub-discipline within paediatric surgery that deals with surgically treating congenital and acquired illnesses in newborns and infants up to one month old.
This is a highly complex sub-speciality that only exists at tertiary paediatric centres. The past few decades have brought about important advances, thanks to improvements in diagnostic techniques, neonatal intensive care and anaesthetics, and surgical techniques and materials. These have radically changed the prognosis for both birth defects and acquired surgical pathologies in newborns.
Neonatal surgery requires detailed knowledge of complex pathologies in patients who also have special conditions that are different from other paediatric patients. The Neonatal and Foetal Surgery Unit covers practically every surgical neonatal pathology, and it is a reference centre both nationally and on a European level. It is part of ERNICA, the European Reference Network (ERN) for Rare Inherited and Congenital Digestive Disorders. In recent years, the Unit has been firmly committed to introducing minimally invasive surgical techniques, achieving excellent results.
We work in conjunction with the Neonatology Department. The Neonatal Intensive Care Unit (NICU) at Vall d’Hebron Hospital is one of the largest in the country and has one of the best survival rates. We have the possibility of performing surgical interventions within the NICU if transporting the newborn patient to the surgical wing would be too risky due to the instability of their condition.
Similarly, we work closely with the Foetal Medicine Unit, whose services include all the currently valid prenatal and intrapartum (EXIT technique) foetal surgery techniques.
The Unit participates in the following sessions and committees: Neonatal Medical-Surgical Session (Tuesdays at 1 pm), Paediatric Airway Committee, Birth Defects Committee.
Within our areas of interest, we highlight oesophageal atresia, a pathology for which our overall survival rate exceeds 95% in patients who do not present complex associated malformations. Patients with long-gap oesophageal atresia continue to be a challenge, as the distance between the ends is so great that a primary repair cannot be done. In these complex patients, besides applying the different classic techniques, we use the Foker technique, which consists of sustained traction on the ends to be connected in order to stimulate their growth, so that oesophageal anastomosis can finally be achieved. In those patients for whom the native oesophagus cannot be saved, we carry out oesophageal substitution via gastric pull-up, with excellent short-term and long-term results.
We have established a comprehensive treatment plan for patients affected by a congenital diaphragmatic hernia (CDH), which includes foetal treatment (using the FETO technique: Foetal Endoscopic Tracheal Occlusion) in cases where CDH has been diagnosed in the foetus and the prognosis is not good. In addition, the hospital offers every type of invasive and non-invasive respiratory support and therapy available today: synchronised mechanical ventilation, HFOV, CPAP, treatment with inhaled nitrous oxide, and ECMO (extracorporeal membrane oxygenation), providing cardiovascular and respiratory support when conventional treatment proves ineffective. In patients with large diaphragmatic defects, we use several types of patches, both synthetic and biological ones, and techniques that use autologous muscle flaps, generally from the abdominal wall.
The main abdominal wall defects we find are gastroschisis and giant omphalocele. We are especially proud of how we handle gastroschisis, which can be associated with severe medical-surgical problems due to the inflammation and thickening of the exposed intestinal loops caused by the irritation produced by the amniotic fluid at the end of gestation. Since 2002, we have been carrying out a strategy to avoid this, consisting of performing a scheduled Caesarian section at 34-35 weeks of gestation. This elective preterm C-section technique allows for the abdominal defect to be closed directly, as it reduces exposure to amniotic fluid. With more than 50 patients treated this way, we have not observed complications linked to prematurity. Instead, we have detected a decrease in the associated complications, an earlier introduction to food, and a reduced hospital stay, as well as better aesthetic outcomes, since the scar is hidden by the belly button. We have vast experience in treating giant omphalocele. For this, we use surgical techniques that employ vascularised flaps, biologic or synthetic mesh, and vacuum-assisted closure (V.A.C.®).
Our overall survival rates for acquired surgical pathologies such as necrotising enterocolitis and intestinal perforation (both in premature and LGA premature - with a birth weight of less than 750g - babies) is comparable to other European reference centres. This is thanks to the application of our philosophy of minimally aggressive surgery and conservative treatment; applying these principles is the underlying reason for our high rates of survival and preservation of native intestine.
Intrauterine or peripartum surgery
Pathologies of the disgestive tract
Pathologies of the abdominal wall
Pathologies of the lungs and respiratory tract
Others
The Paediatric Surgery Department at Vall d’Hebron University Hospital is a reference in Catalonia for the treatment of most paediatric surgical problems and in the rest of Spain for specific procedures. Our mission is to care for paediatric patients with surgical concerns.
Pediatric Surgery Training Itinerary
Paediatric Surgery is a discipline that covers a wide range of pathologies, from congenital, acquired, malformation, infectious and tumoral conditions, including thoracic, abdominal and genitourinary issues.
Our involvement in patient care spans from before birth (foetus, prenatal period) through to late adolescence.
To provide the highest quality, our service is structured into different subspecialities:
This innovative structure allows us to achieve a high level of super-specialisation and expertise in a specific area of modern paediatric surgery, which further benefits our paediatric patients and ensures a higher quality of care.
Our Paediatric Surgery department was the first in Spain to introduce a Foetal Surgery Programme, forming part of the multidisciplinary Foetal Medicine programme.
Similarly, we were the first hospital in Spain to perform paediatric transplants, kidney transplants from 1981 and liver transplants from 1985, including being the first to carry out a reduced liver transplant in 1987 and the first ‘split’ liver transplant in 1992. Our Hospital and our Department remain directly involved in the liver and kidney transplant programmes, which are among the highest volume and best-performing in the country.
We are committed to high-complexity surgery, introducing increasingly minimally invasive techniques to various paediatric-age groups, including neonatal surgery, and even venturing into foetal surgery. Among these minimally invasive techniques, we incorporate robotic surgery. Starting in 2009, we were the first paediatric hospital in the country to develop a robotic surgery programme.
Our department is currently accredited by various national and international benchmarking programmes: CSUR (Centres, Services and Units of Reference of the Ministry of Health) for Neuroblastomas, Childhood Sarcomas, Paediatric Liver Transplant, Paediatric Kidney Transplant, Bladder Exstrophy and Epispadias.
We are also ‘Full-Members’ of various ERN (European Reference Networks) such as ERNICA and EUROGEN, as well as Paediatric Oncology and Erythropathies.
In 2012, we received the Certificate of Hospital Accreditation for Specialist Training in Paediatric Surgery from the European Board of Paediatric Surgeons, with the endorsement of the UEMS, as a centre of excellence for the training of paediatric surgeons and in 2023, we were again re-accredited as a Centre for Training in Paediatric Surgery.
Our programme allows residents to gain comprehensive training in all areas of paediatric surgery, which, unlike programmes at other centres, encompasses everything from organ transplants to foetal surgery, including neonatal, oncological, thoracic, digestive and urological surgeries. Training emphasises the most advanced minimally invasive techniques, including robotic surgery. Our simulation laboratory for minimally invasive surgery enables our residents to train in an appropriate and safe environment.
During the first semester, residents undergo adult general and thoracic surgery training. Subsequently, they join our department, rotating through the various subspecialities according to their training programme. During on-call shifts (4-5 per month), the resident is accompanied by a senior doctor who is physically present. During continuous care, paediatric surgical emergencies are covered, and they participate in the paediatric polytrauma care programme. During these shifts, we encourage the resident’s autonomy in surgical decision-making and their proficiency executing the various surgical techniques performed. Furthermore, residents are integrated into paediatric transplant programmes (liver and kidney).
The training pathway for residents in our centre ensures learning across all paediatric surgical subspecialities, encompassing everything from outpatient surgeries to highly complex surgeries such as intricate oncological surgeries, complex anorectal malformations and solid organ transplants. Additionally, there is a six-month period where optional rotations can be undertaken, where the resident can choose from options available in our centre including: paediatric plastic surgery, paediatric cardiovascular surgery, paediatric neurosurgery, paediatric anaesthesia, paediatric maxillofacial surgery.
Continued training sessions are held between members of the department and external specialists:
During the final year of training, a rotation to international centres of excellence is encouraged. Throughout the residency, clinical and laboratory research is promoted, encouraging the presentation of papers at national and international conferences and publications.
Furthermore, training courses deemed necessary for the speciality are provided during the residency:
Throughout rotations in various units, the relevant team provides information on courses and subspecialist conferences that are more appropriate to attend and/or submit papers. There are also specific courses which, depending on the resident’s interest, can be optional or mandatory.
In the field of research, residents are encouraged to participate in the department’s active research initiatives and new research that may or may not be related to these research lines and which may result in the pursuit of a doctoral thesis.
Currently, at the Vall d’ Hebron Research Institute (VHIR) we maintain several established paediatric research lines in experimental surgery, specifically focusing on foetal surgery. In 2015 we created the Bioengineering group, Cellular Therapies and Surgery in Congenital Malformations, which is currently researching prenatal treatment of spina bifida and congenital diaphragmatic hernia. Moreover, among other projects, we have conducted research on amniotic band syndrome, gastroschisis, oesophageal atresia and bladder augmentations. These translational research programmes have enabled patients to benefit from them, notably the FETO techniques (foetal tracheal occlusion in the serious congenital diaphragmatic hernia) and the prenatal repair of the myelomeningocele, initially by open surgery and since 2015 via fetoscopic methods.
Regarding clinical research, the first multicentre randomised controlled trial on the treatment of parapneumonic empyema stands out, comparing video-assisted thoracoscopy to drainage and use of fibrinolytics, subsequently published in the journal Pediatrics. Additionally, there are numerous clinical research lines across all units, with publications in national and international journals.
At the same time, we collaborate with other research teams, particularly in the field of paediatric oncology, as well as in collaborative studies and international multicentre studies. Experimental research groups:
Paediatric Surgery, Children's Hospital and Woman's Hospital
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