经皮内镜胃造瘘和小肠造瘘术的临床应用价值

目的探讨经皮内镜胃造瘘术(percutaneous endoscop ic gastrotomy,PEG)和经皮内镜小肠造瘘术(percutaneous endoscop ic jejunostomy,PEJ)的临床应用价值。方法1996年6月~2006年4月行PEG胃肠营养97例;行PEG胃肠减压加PEJ小肠内营养34例。结果131例共行PEG、PEG加PEJ 146例次,其中PEG 112例次(15例行造瘘管置换)、PEG加PEJ 34例次,手术成功率100%。5例患者出现造瘘管周围皮下感染。所有患者造瘘管置入后营养迅速恢复,停止静脉补液。131例平均随访10个月无严重并发症发生。结论PEG和PEJ作为胃肠减压和肠内营养替代鼻饲的一种新的治疗方法,具有安全、降低医疗费用和并发症少的优点,如有条件,应当选用。     

Endoscopic percutaneous cecostomy (EPC)

Summary Endoscopic decompression of the distended colon has become a useful method of treating non-obstructive colonic ileus. We propose a method of establishing a cecal fistula by means of percutaneous puncture of the colon and pull-through of a Pezzer catheter. Although until now we have only performed this procedure twice, it seems to be a valuable therapeutic approach in cases of paralytic distension of the large bowel.     

Laparoscopic-Assisted Gastric Button Placement: a Valuable Alternative for a Percutaneous Endoscopic Gastrostomy (PEG)

A percutaneous endoscopic gastrostomy remains the first choice when oral feeding is difficult. In some patients however an endoscopic placement of a gastrostomy tube is not possible. As an alternative, a laparoscopic-assisted insertion of a gastric button was performed to provide enteral feeding in seven patients. Enteral feeding could be resumed within one or two days after the procedure and no complications were encountered. This minimal invasive technique has certain advantages over a surgical gastrostomy by laparotomy. Therefore, a laparoscopically inserted gastric button should be considered a valuable alternative if percutaneous endoscopic gastrostomy is no longer possible.     

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Combined with CT-GC

Purpose: Despite the widespread use of percutaneous endoscopic gastrostomy (PEG) tubes, their placement may be associated with a variety of complications, including gastrocolic fistula. Materials and Methods: In total, seven high-risk individuals diagnosed using computed tomography (CT)-gastrocolonography (GC) underwent laparoscopic-assisted PEG (LAPEG) placement. Study endpoints included the success of LAPEG under local anesthetic and intravenous sedation, inability to thread the PEG tube, the eventual tube location, the number of tube adjustments needed, adverse events, the operating time, and PEG tube-related infection. Results: In total, 135 PEG procedures were performed during this study. Successful CT-GC was achieved in all 135 patients, and we successfully used a standard PEG technique to place the gastrostomy tube in 128 patients (95%). In seven patients (5%), the LAPEG technique was used because the transverse colon became interposed between the abdominal wall and the anterior wall of the stomach. LAPEG procedure-related minor complications were observed in two patients. Conclusions: LAPEG combined with CT-GC can be used for patients with difficult anatomical orientations and may minimize the risk of complications in PEG placement.     

Pediatric surgery workforce: supply and demand

Introduction

Recent studies report a shortage of pediatric surgeons in the United States. We surveyed members of the American Pediatric Surgical Association (APSA) to estimate current workforce and demand and to provide data for workforce planning.

Methods

We conducted a survey of 849 APSA members to provide workforce data on their communities as follows: the number of active, retired, or inactive APSA surgeons; non-APSA fellowship graduates; surgeons without accredited fellowship training; and the estimated demand for additional pediatric surgeons. Internet search engines identified surgeons and practices offering pediatric surgical services. The US Census Metropolitan Statistical Areas (MSAs) defined service areas with populations of 100,000 or more.

Results

Of 137 MSAs with APSA members in practice, we obtained data from 113 (83%), with 247 (29%) of 849 surgeons responding. We estimate that the current pediatric surgical workforce consists of 1150 surgeons, with APSA members in active practice (60%) forming the single largest group, followed by general surgeons (21%). The percentage of active APSA surgeons was greater than the percentage of general surgeons in the 50 largest MSAs (76% vs 2%, respectively), whereas the opposite was observed in the smaller MSA ranked more than 51 in population (37% vs 46%, respectively). American Pediatric Surgical Association respondents estimated a national demand for 280 additional pediatric surgeons. Active APSA surgeons plan to delay retirement (8% of respondents) because it would leave their group or community shorthanded; 2% reported that retirement would leave the community without a pediatric surgeon.

Discussion

Workforce shortage in pediatric surgery is a problem of number and distribution. Incentives to direct trainees to underserved areas are needed. General surgeons provide pediatric services in many communities. Surgical training should include additional training in pediatric surgery.     

Outcomes research in pediatric surgery. Part 1: overview and resources

Outcomes research in pediatric surgery can be defined as the analysis of pediatric surgical outcomes and their predictors at different levels in the health care delivery system. The objectives of this article are to understand the differences between outcomes research and clinical trials as well as to gain familiarity with public multispecialty and specialty-specific databases. The utility of outcomes research extends to benchmarking the quality of care, refinement of management strategies, patient education, and marketing. Assessment of the integration of a new surgical technique into the health care system is best determined by examining a population-based registry, whereas comparative efficacy of surgical procedures is best assessed by randomized clinical trials. In the first part of this 2-part series, an overview and brief outline of available resources for outcomes research in pediatric surgery are reviewed. In part 2, a template is presented on how to structure and design an outcomes research question.     

Totally Endoscopic Robotic‐Assisted Cardiac Surgery in Children

Robotic surgery for intracardiac pathologies in children is relatively uncommon. This study presents our initial experience with robotic‐assisted cardiac surgery in children. We also present the feasibility and safety of robotic surgery in children. From May 2013 to June 2018, 30 children underwent totally endoscopic robotic atrial septal defect closure (n = 22), right‐sided (n = 5) or left‐sided (n = 1) partial anomalous pulmonary venous connection repair, tricuspid valve annuloplasty (n = 4), and mitral valve replacement (n = 2, due to Barlow and rheumatic diseases). The mean age of the patients was 16.1 ± 1.1 years (range, 13–17) and the mean weight was 56.7 ± 0.1 kg (range, 42–77). Associated anomalies included left persistent superior vena cava (n = 2) and the absence of innominate vein (n = 1). All procedures were completed uneventfully. Operation time was 4.1 ± 0.6 h. No patient was converted to thoracotomy or sternotomy. Cardiopulmonary bypass and aortic clamping times were 90.6 ± 28.0 (range, 45–136) and 48.6 ± 24.9 (range, 15–94) min, respectively. The mean ventilation time was 3.7 ± 1.2 h and hospital stay time was 3.3 ± 0.7 days. No right phrenic nerve injury, hemorrhage, or blood transfusion were noted. One patient had postoperative pneumothorax, and 1 had supraventricular arrhythmia. Follow‐up was a mean of 1.7 years (range, 1–52 months). Patients were healthy and no residual intracardiac defect was observed on echocardiography examinations. There was no operative or follow‐up mortality. Robotically assisted cardiac surgery is a feasible and safe approach in selected pediatric patients. In the future, new generation robotic devices may offer an alternative surgical approach in cardiac surgery for younger children with lower body weight.     

Pediatric surgery workforce: population and economic issues

Background

Whether a shortage of pediatric surgeons exists in the United States, such as those observed in the total physician and general surgical workforces, is an important issue that will affect decisions regarding training, credentialing, and reimbursement. Our goal was to update information regarding the demand and supply of pediatric surgeons.

Methods

Online American Pediatric Surgical Association (APSA) membership directory gave numbers of pediatric surgeons and their residence by metropolitan statistical areas (MSA), defined by the US census. Population and economic data were obtained from appropriate US government agencies.

Results

There were 835 APSA members and 375 MSA. Eliminated were 86 MSA (with 12 APSA members) with incomplete data, 14 MSA (0 members) with populations less than 100,000, and 25 members with listed locations outside an MSA. The remaining 798 members and 275 MSA comprised the study. The number of APSA members in an MSA correlated closely with MSA population (R² = 0.836) and 2006 births (R² = 0.767). Metropolitan statistical areas without an APSA member had a smaller population and birth rate than those with one or more members (P = .0001). An MSA with 1 APSA member had a higher population (P = .0003) and births per APSA member ratios (P = .0014) than MSA with 2 and 3 or more members. The presence of a medical school or a pediatric training program had no effect on population or births-to-APSA member ratios. There was no correlation between numbers of APSA members and state GDP or state GDP per capita. We used a low, medium, and high threshold to predict the need for pediatric surgeons based upon population per APSA member ± 1 SD (272,466 ± 163,386) to predict a need of 82 to 1344 pediatric surgeons, an increase in the APSA membership by 10% to 168%.

Conclusion

Based on population estimates and APSA membership, a current shortage of pediatric surgeons exists. Measures should be taken to address this workforce issue.     

Endoscopic management of bariatric complications

Bariatric metabolic surgery is a common elective general surgical procedure. Sleeve gastrectomy and Roux-en-Y gastric bypass are the two most common surgeries performed. They are considered safe with low morbidity and mortality. Leaks and bleeding are early complications after surgery. Endoscopy plays an important role in the diagnostic and therapeutic management of these complications. Advances in endoscopic interventions have increased the available options. It is important that healthcare professionals in non-specialized bariatric units who encounter these complications liaise with specialized units for advice and management.     

Endoscopic medial parascapular approach to the thoracic spine

Background The traditional endoscopic-assisted approaches to the thoracic spine between the 4^th and 8^th thoracic vertebrae, whether in lateral or prone positions, are done ventrolateral to the scapula. Accordingly, the distance between the working portal and the spinal target is relatively long, and this increases the difficulty of the endoscopic surgery. Exposure of the spinal target necessitates excessive retraction and/or deflation of the corresponding lung. Both maneuvers are undesirable, particularly in old people with chronic obstructive lung disease.Methods This paper describes an endoscopic-assisted medial parascapular approach in the prone position that offers the surgeon a relatively short access to the upper-mid-thoracic spine. Fifteen patients (10 men and five women), mean age 68 years, with anterior lesions located between the 4^th and 8^th thoracic vertebrae, constituted this prospective study. The type of the anterior endoscopic procedure varied according to the surgical indication and was as follows; biopsy from a paravertebral swelling in two patients, debridement and fusion in four patients with spondylodiscitis, corpectomy and replacement with telescope cage (X-Tenz) in five patients with spinal tumors, corpectomy and replacement with X-Tenz in two patients with vertebral osteonecrosis, and intersomatic fusion in two patients with fractures. Posterior transpedicular fixation was done in 13 patients in the same sitting.Results Conversion to open thoracotomy was not needed. There were no instances of spinal wound infections, neurological deficits, dural tears or vascular injuries. Subcutaneous emphysema developed in one patient and resolved spontaneously. The mean blood loss was 1006.7 ml. Neither pseudarthrosis nor metal failure was encountered. The segmental kyphotic angle decreased from 13.6° at the preoperative period to 9.6° at the immediate postoperative period and reached 11.7° at the end of the follow-up.Conclusions The endoscopic medial parascapular approach, done in the prone position, provides the shortest access to anterior spinal lesions between the 4^th and 8^th thoracic vertebrae. This approach is associated with minimal manipulation and retraction of the lung so that a double-lumen tube is not needed.     

胃肠肿瘤腹腔镜手术中内镜检查的应用价值

目的评价胃肠肿瘤腹腔镜手术中内镜检查的应用价值。方法回顾分析2004年1月～2008年11月我院505例胃肠肿瘤腹腔镜手术中39例(7.7%)术中内镜检查的临床资料。结果 32例以定位病变为指征,其中30例找到病变,检出率达93.8%(30/32);5例以评价吻合口为指征,术后均未出现吻合口狭窄,其中3例同时内镜定位病变切除了合并存在的结肠腺瘤;1例术中出血,行术中内镜明确了出血部位;1例拟在腹腔镜辅助下行内镜下胃脂肪瘤切除,因内镜下注射后抬举征阴性,提示病变深度超过黏膜下层,故改为腹腔镜下切除。结论术中内镜检查对腹腔镜胃肠肿瘤手术病变定位及吻合口评估有重要价值。     

Transperitoneal Laparoscopic Adrenalectomy in Children

Purpose:

The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults. The aim of our study was to describe the safety and feasibility of minimally invasive adrenalectomy in children on the basis of surgical skills and results.

Materials and Methods:

This was a retrospective study of 4 pediatric laparoscopic adrenalectomies performed at our center between 2009 and 2012. All patients underwent transperitoneal lateral laparoscopic adrenalectomies (2 right and 2 left adrenalectomies).

Results:

Four laparoscopic adrenalectomies were performed. Indications for surgery were neuroblastoma in 2 patients, secernent adrenocortical tumor in 1 patient, and adrenocortical nodular hyperplasia in 1 patient. Patients had a mean age of 87 months (range, 17–156 months) at diagnosis, and the average lesion size was 3.23 cm (range, 0.7–6.4 cm). All laparoscopic adrenalectomies were successful, no conversions to open surgery were required, and no postoperative complications or deaths occurred. The average operating time was 105 minutes (range, 80–130 minutes), blood loss during surgery was minimal, and the mean postoperative hospital stay was 3.75 days (range, 3–5 days). None of the patients showed signs of recurring disease at 15-month follow-up.

Conclusions:

Laparoscopic adrenalectomy is a safe, feasible, and reproducible technique offering numerous advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications. It also provides good visibility and easy access to other organs.     

小剂量氯胺酮咪唑安定合剂小儿基础麻醉850例临床应用

为改进小儿基础麻醉法，笔者研究了小剂量氯胺酮，咪唑安定合剂的临床效果与副作用，观察８５０例ＡＳＡＩ－Ⅱ级，年龄３ｄ－１４岁，行中小手术的病人。合剂由氯胺酮１００ｍｇ（２ｍｌ）与咪唑安定１５ｍｇ（３ｍｌ）配制而成，剂量为０．１０－０．１３ｍｌ／ｋｇ，咪唑安定０．３０－０．３９ｍｇ／ｋｇ），手术均在基础麻醉与区域阻滞配合不下完成。结果显示，此方法有给药方便，效果迅速而确切，苏醒快及副作用小等优点，比硫     

Endoscopic transsphenoidal resection of a large chordoma in the posterior fossa

Summary Encouraged by an experience with endoscopic transsphenoidal pituitary surgery, an endoscopic transsphenoidal technique was applied in a patient with a large chordoma in the posterior fossa. The patient was a 40-year-old man with a two-year history of progressive ataxia, a memory disorder and emotional instability. A magnetic resonance (MR) scan of the brain revealed a midline posterior fossa mass measuring 4 cm in diameter located between the clivus and the brainstem. The basilar artery and its bifurcation were encased by the tumor and the brainstem was also distorted by the tumor. Obstructive hydrocephalus was treated previously with a ventriculoperitoneal shunt and fractionated external beam radiation treatment was given without histological diagnosis at another hospital. Subtotal resection of the tumor was achieved utilizing an endoscopic transsphenoidal technique through the patient's nostril. The portion of the tumor located behind the basilar artery was not resected in order to protect the brainstem perforating arteries. The patient showed dramatic improvement of his symptoms postoperatively. Residual tumor located behind the basilar artery was treated by stereotactic gamma-knife surgery. This is the first reported case of a large posterior fossa chordoma being treated by an endoscopic transsphenoidal technique.     

经皮肾腔内肾乳头活检技术的建立及临床意义

目的：借助微创经皮肾穿刺取石术（MPCNL）建立经皮肾引导直视下进行肾乳头活检的技术,为尿结石病因的基础研究提供新的途径.方法：2005年5月～2007年10月对12例复杂肾结石行MPCNL,对术中发现已有肾乳头钙化斑形成的患者采用经皮肾引导直视下进行肾乳头活检,肾乳头活检标本送电镜观察.结果：12例患者术后无一例出现严重血尿、肾出血的并发症,无一例因严重并发症而再次手术或介入治疗,手术后随访肾功能恢复良好.结论：经皮肾腔内肾乳头活检技术安全、可行,能够在直视条件下获取肾乳头钙化斑组织进行形态学以及蛋白或基因水平的研究,为将来尿结石形成的基础研究提供了一条新的途径.     

小儿原发性椎管内肿瘤(附77例分析)

目的：作者通过对77例小儿原发性椎管内肿瘤进行综合分析。旨在为临床医生提供详尽材料，以关注此病的诊断与治疗，方法：对77例原发性椎管内肿瘤的病理分型，发病率，发病部位进行了回顾性分析。特别是对MRI的影像特点进行了重点论述。结果：77例均行手术治疗，肿瘤全切76例，仅1例室管膜瘤行部分切除治疗，全部病例获得随访，术后症状消失或明显改善76例，脂肪瘤及脂肪纤维瘤占48%，皮样囊肿及畸胎瘤占22%，蛛网膜囊肿占15.6%。神经纤维瘤占4%，80%的病人肿瘤发生在腰骶部，所以常常合并脊髓栓系综合征，结论：（1）小儿原发性椎管内肿瘤以先天性的肿瘤为常见，而成人常见的神经鞘膜瘤和神经胶质瘤不多见。（2）MRI是椎管内肿瘤目前最精确的诊断方法，对肿瘤的治疗和预后价值极大，应广为利用。（3）一旦确诊应尽早手术治疗。     

经皮腰椎间孔镜手术的穿刺定位策略

目的探讨经皮腰椎间孔镜手术穿刺定位的策略。方法 2009年12月～2011年6月对218例下腰椎疾病行经皮腰椎间孔镜手术240次,根据患者的病史、临床表现及X线片等影像学资料,确定腰椎疾病的不同类型,术前制定定位麻醉计划,结合术中C形臂X线机定位,决定穿刺点及穿刺方向。结果 228例次(228/240,95.0%)一次穿刺成功,12例次(12/240,5.0%)重新定位穿刺。麻醉穿刺时间5～18 min,平均9.8 min。5例发生脑脊液漏:2例硬膜囊内镜下明显破裂、神经根损伤,术后并发患肢麻木无力,经保守治疗逐渐好转;3例硬膜囊无明显破裂,未特殊处理。2例发生手术椎间隙感染。2例穿刺过程中出现腹痛,经调整穿刺方向后症状减轻消失。218例术后随访4～18个月,平均13.5月,其中88例随访超过1年,术前功能障碍指数(Oswestry disability index,ODI)56.5±21.1,术后末次随访25.4±9.1,85.2%(75/88)的患者有改善;术前视觉模拟评分(visual analog score,VAS)为(6.9±3.1)分,术后末次随访为(2.8±2.2)分,88.6%(78/88)的患者有改善。结论椎间盘突出偏后外侧尤其是椎间孔附近、包容性椎间盘突出拟行髓核射频消融或纤维环成形者,穿刺角度与中央型突出穿刺路径区别对待;侧位观穿刺要紧贴上关节突边缘,针尖对准椎间盘中央。腰椎间孔狭窄、侧隐窝狭窄病人,若主要为椎体后缘增生钙化,路径稍向前平移,若主要由椎小关节增生引起,穿刺线向后平移。     

Perception and use of minimal access surgery simulators in pediatric surgery training programs

Background/Purpose

In the current time-restricted training environment, simulator use in surgical teaching is receiving increasing attention. A large body of literature addresses simulators' effectiveness in surgical education. No prior studies assess how widely simulators are actually being used or attitudes about their effectiveness of those involved in training.

Methods

Surveys were e-mailed to all current pediatric surgery trainees and training directors. Queries examined respondents' perceptions about surgical simulators' usefulness and to what extent they are used in their programs. Other questions assessed obstacles to simulator use.

Results

Response rates were high (47% of program directors and 67% of current fellows). Nearly all respondents felt laparoscopic simulators improve training efficiency (88%). About half (55%) report regular simulator availability to trainees. Only 21% of programs have current or planned simulation curricula. Less than half of the training directors (32%) and about half of the fellows (55%) felt they have actually significantly improved trainees' skills.

Conclusions

Trainees and training directors placed significant importance on simulator use in pediatric surgery training. However, most did not feel that simulators had actually improved the trainees' laparoscopic skills. Wider availability of simulation laboratories and protected time for using them would enhance the impact of simulators on pediatric surgery training.