上位肾分肾功能<10%重复肾患者保留或不保留上肾手术的预后比较-单中心回顾性队列研究

目的比较上位肾分肾功能<10%的重复肾患者行保留或不保留上肾单位手术的预后情况。方法回顾性分析中国医科大学附属盛京医院2008年1月至2017年6月收治的49例上位肾分肾功能<10%的重复肾畸形患者临床资料,依据不同治疗方案分为保留上肾单位组(n=22)和不保留上肾单位组(n=27),对两组术后并发症发生率和再手术率进行统计学分析。结果与不保留上肾单位组相比,保留上肾单位组术后并发症发生率(22.7%vs.3.7%)和再手术率(9.1%vs.0.0%)更高,但差异无统计学意义(P>0.05)。与不保留上肾单位组相比,保留上肾单位组患者中位手术年龄更小(16.5个月vs.33.0个月),差异有统计学意义(P=0.006)。而两组间性别、侧别、术前是否存在输尿管末端膨出/异位、术前上位肾分肾功能和术前患侧上肾输尿管直径差异均无统计学意义(P>0.05)。结论上位肾分肾功能<10%重复肾患者如需手术治疗,初次手术方式可根据医生和患者家长意愿,选择较为简单的手术方式。     

Laparoscopic management of obstructed partial duplex with Y ureteric configuration

An 11-year-old girl underwent a laparoscopic upper-to-lower moiety ureteropyelostomy for lower moiety pelviureteric junction obstruction associated with Y ureteric duplication. She presented with left flank pain and was noted to be hypertensive with microscopic haematuria on admission. An abdominal ultrasound scan revealed a duplex left kidney with gross lower moiety pelvicalyceal dilatation. A subsequent MAG-3 scan demonstrated reduced differential function in the left lower moiety. A laparoscopic transmesocolic approach confirmed a dilated lower moiety pelvis and revealed the Y ureteric duplication. An upper to lower moiety ureteropyelostomy and insertion of a JJ stent is described in the accompanying video. The child was discharged home on the second day post operation. Postoperative imaging showed good decompression and improved differential function. The child has been completely well and normotensive at 2 years' follow-up.     

腹腔镜下重复肾半肾切除术手术路径探讨

目的 探讨经后腹腔镜途径和改良经脐腹腔镜途径实施小儿腹腔镜下重复肾半肾切除术的效果,评估两种手术途径的临床价值.方法 回顾性分析2006年9月至2010年10月北京军区总医院附属八一儿童医院等收治的腹腔镜重复肾半肾切除术患儿临床资料.后腹腔镜组27例,为2006年9月至2009年9月连续收治的病例;改良经脐腹腔镜组1...     

Laparoscopic management for non-traumatic colon perforation in children

Purpose

Although recent reports have seen an increase in acceptance of laparoscopic surgery as treatment for traumatic colon injury, its role in the management of non-traumatic colon perforation in children has not been reported. In this study, we review our experience in laparoscopic non-resectional management for children who presented with non-traumatic colonic perforation.

Methods

Between October 2003 and May 2011, 15 children who had been diagnosed with colonic perforation and underwent laparoscopic surgery were included in the study. Their medical records were reviewed for analysis.

Results

The clinical manifestation of non-traumatic colon perforation in children was non-specific. The most likely aetiology was infective colitis. Solitary perforation at the caecum was the most common finding. The exact perforation site could not be identified in 3 patients. Nine patients had primary closure while 3 patients underwent wedge resection. The single trocar laparoscopic surgery was successful in 12 patients. The mean postoperative hospital stay was 7.3 days.

Conclusion

For children presenting with suspected non-traumatic colon perforation, laparoscopic management is the desirable approach. The peritoneal lavage, wedge excision and primary repair can be performed with single trocar techniques and is associated with minimal morbidity. Future prospective studies are needed to compare this minimally invasive approach with conventional open surgery.     

The role of MR imaging for the assessment of complicated duplex kidneys in children: preliminary report

OBJECTIVE: To determine whether MR imaging, including MR urography, is able to assess complicated duplex kidneys and to determine the possible role of MRI compared to other imaging techniques in such uropathies. MATERIAL AND METHODS: Twenty consecutive patients (age 1 month-11 years) presenting with a suspicion of a complicated duplex kidney were prospectively studied with MRI and MR urography. The examinations were performed on a 0.5-T machine using routinely available sequences that were optimised to the patient's age and size. MR images were reviewed separately by two observers blinded to the patient history. They were asked to assess the presence of a duplex kidney, the presence of an abnormality that may require surgery and to indicate the type of the inferior ureteric insertion. A qualitative gradation of these results was performed on the basis of the final diagnosis provided at endoscopy (n = 6) or surgery (n = 14). MR results were compared to those provided by US examinations and excretory urography, when available, and a non-parametric statistical analysis was performed. RESULTS: MRI differentiated well between the upper and the lower poles of the kidneys and correctly answered the three questions in all 20 patients. The two observers agreed completely in all the 20 patients. MR was statistically superior to both US and excretory urography in the evaluation of the distal ureter (P < 0.05). CONCLUSIONS: MRI provides a precise assessment of the complications associated with duplex kidneys. Its optimal role seems to be the assessment of ectopic extra-vesical ureteric insertions and whenever an occult upper pole is suspected.     

腹腔镜治疗儿童先天性食管裂孔旁疝

目的 分析和研究腹腔镜下治疗儿童先天性食管裂孔旁疝的经验.方法 2005年至2010年诊治10例食管裂孔旁疝的患儿,其中5例为混合性食管裂孔疝.年龄8个月～10岁,平均年龄5.2岁,男6例,5例表现为贫血,2例反复呼吸道感染,3例反复呕吐伴营养不良,术前通过胃肠钡餐检查(GI)及胸部CT检查,均发现右侧胸腔占位及胃泡影,其中2例胸腔被腹腔内容物占据.采用改良Thal方法,腹腔镜下修补食管裂孔旁疝,切除疝囊,关闭裂孔,并作抗反流.结果 全部病例在腹腔镜下行改良Thal法治疗,手术时间90～150 min,术中发现疝孔大小3.0～5.5cm,大部分胃组织疝入后纵隔,其中3例患儿伴有结肠疝入,同时合并有4例胃扭转,患儿均有巨大的疝囊组织.术后行GI检查,无反流,胃泡位置正常,胃肠功能恢复好,术后3～5 d出院,随访6个月,贫血及术前症状均消失,生长发育良好.结论 先天性食管裂孔旁疝通常伴有其他并发症,需要早期诊断、早期治疗,如果缺损较大伴有食管贲门交界处疝入后纵隔,需要在修补裂孔的基础上做抗反流手术,腹腔镜下改良Thal是一种有效的治疗方法.

Abstract：

Objective The aim of this study was to analyze our experience of diagnosis and treatment of congenital paraesophageal hiatal hernia(PEHH). Methods Between 2005 and 2010, the records of 10 patients with PEHH were retrospectively reviewed. Five patients had a combination of sliding and paraesophageal hernia. The age ranged from 8 month to 10 year. Average age was 5. 2 year.Five case presented with anemia,2 cases with recurrent respiratory infection. 3 cases with vomiting and failure to thrive. Diagnosis was confirmed by upper gastro-intestinal constrast study and chest CT scans. All patients present with right paracardiac opacity and gas bubbles in the right lower thorax. In two cases, the opacity occupied the right thorax. We carried out modified Thal procedure to repair the paraesophageal hiatal hernia. Results Thal procedure was successfully completed in all patients. The.operation time ranged from 90 minutes to 150 minutes. The diameter of these hernia ranged from 3 to 5. 5 cm with most of stomach displaced into the thorax. Three pateints had transverse colon herniated into the thorax. In four patients, the gastric volvulus was encountered. Post-operatively, there was no evidence of gastro-esophageal reflux. Patients were discharged in 3 to 5 days. Symptoms subsided and the growth of the children was normal. Conclusions Early diagnosis and treatment for congenital paraesophageal hiatal hernia is recommended. Large defect is associated with displacement of gastro-esophageal junction into the thorax. Additional antireflux procedure to is recommended. The modified Thal procedure is an effective way of repairing PEHH.     

Cystic kidneys in children

From 1976-1987 a total of 26 infants and children with polycystic kidney disease were treated at the Children's Hospital of the Medical School Hannover. 13 of them suffered from infantile recessive polycystic kidney disease (IRPKD), and 13 from adult dominant polycystic kidney disease (ADPKD). IRPKD was diagnosed at a median age of 0.33 years (range 1 day-13 years), ADPKD at 6.0 years (3 days-14 years). Of those with IRPKD two infants died from bacterial infection and two others developed terminal renal insufficiency at the age of 8 years, while the others are living and 1-20 years old. All those suffer from severe arterial hypertension and have reduced renal function, but only 5 developed signs of liver fibrosis. Of those with ADPKD one infant died from sepsis and renal insufficiency, while the others are well and now 2-17 years old. Only one child needs an antihypertensive treatment. The most important criteria to differentiate IRKPD and ADKPD in children are the genetic transmission, age of first manifestation, hypertension and renal function. The prognosis is much more severe in IRPKD than in ADPKD, but is not as infaust in IRPKD as often assumed.     

Laparoscopic ipsilateral ureteroureterostomy in the management of ureteral ectopia in infants and children

Objective

We report our initial experience, and describe our technique, in performing laparoscopic ipsilateral ureteroureterostomy (IUU) in the pediatric population.

Materials and methods

An IRB-approved, retrospective review of all patients undergoing laparoscopic IUU at our institution between 2006 and 2009 was performed. Demographic data, mode of presentation, underlying diagnosis, operative parameters, complications and follow-up data were analyzed. Cystoscopy, retrograde pyelograms and ureteral stent placement into the lower pole ureter were performed at the beginning of all cases. All were performed via a transperitoneal approach. An end-to-side ureteral anastamosis was carried out along the proximal lower pole ureter. No drains were left in place. Urethral catheters were left for 48 h.

Results

There were seven patients in the series. All were female with a mean age of 84 months (11舐190). Diagnosis was an ectopic ureter in six patients and a ureterocele in one patient. No patient required conversion to an open approach. Mean total operative time was 187 min (140舐252). Mean hospital stay was 2 days (1舐4) with a mean follow up of 8 months (1舐15). No complications occurred postoperatively. Follow-up studies demonstrate decreased or resolved hydronephrosis in all cases.

Conclusions

In our initial experience, laparoscopic IUU can be accomplished in a safe and effective manner with minimal complication.     

Laparoscopic and conventional appendicectomy in children: outcomes in English hospitals between 1996 and 2006

Background  Laparoscopic appendicectomy is increasingly used in children. This national retrospective study compared outcomes of paediatric open and laparoscopic appendicectomy. Methods  Length of stay, readmission rates and mortality in children undergoing open and laparoscopic appendicectomy in English NHS Trusts between 1 April 1996 and 31 March 2006 were compared. Procedures coded as emergency excision of appendix (OPCS-4 H01) on the Hospital Episode Statistics (HES) database in patients less than 15 years of age were included. Multivariate analysis was used to identify independent predictors of length of hospital stay and mortality. Results  Eighty-nine thousand, four-hundred and ninety-seven (89,497) appendicectomies were studied; of which, 2,689 (3%) were performed laparoscopically. The percentage of laparoscopic cases rose from 0.6 to 8.4% between 1996 and 2006 (Pearson’s r = 0.954, P < 0.001). Length of stay (median 3, interquartile range 2 days, P = 0.068) and 28-day readmission rates were similar (6.3 vs. 7.2%, respectively; P = 0.072) between groups. No independent hospital stay advantage for laparoscopy was observed (P = 0.121). No difference in 30-day mortality (P = 0.986) or 365-day mortality (P = 0.598) was demonstrated. Conclusion  Hospital stay, readmission rates and mortality are similar following laparoscopic and open appendicectomy in children.     

Scintigraphic features of duplex kidneys on DMSA renal cortical scans

The spectrum of manifestations of duplex kidneys on ^99mTc-dimercaptosuccinic acid (DMSA) renal cortical scans and correlating findings on other imaging modalities are presented. Relevant embryology of the duplex systems and technical aspects of DMSA scintigraphy are reviewed.     

Laparoscopic ureteral ligation (clipping): A novel,simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

ObjectiveA simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper.Materials and methodsProspectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy.ResultsMedian age was eight years (range 4–17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US.ConclusionLaparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.     

Bilaterally obstructed ureteropelvic junction of the upper moieties in a complete duplex collecting system

Maternal ultrasound is a routine examination in prenatal evaluation. The number of fetal abnormalities detected has been increasing, and includes fetal hydronephrosis which is secondary to ureteropelvic junction obstruction in 80% of cases. We report a case of a 1-year-old female infant with hydronephrosis prenatally detected by ultrasound. After close postnatal follow-up and diagnosis, she eventually underwent a definitive reconstructive procedure. This is the first reported case of a bilateral ureteropelvic junction obstruction of the upper moieties of a duplex collecting system.     

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population

ObjectiveDespite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique.Patients and methodsFrom August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9–67) months. In all cases, a non-functioning upper pole with an obstructive (n = 4) or refluxing (n = 1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars.ResultsMean follow-up was 42.4 (±7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170–210) min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4–7) days. All patients were followed using duplex sonography.ConclusionsThese data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.     

针式腹腔镜治疗小儿腹股沟斜疝的临床应用

目的 探讨针式腹腔镜治疗小儿腹股沟斜疝的可行性。方法 总结采用针式腹腔镜治疗２３例小儿腹股沟斜疝的手术方法及疗效。手术方法：气管插管,静脉复合麻醉,人工气腹。于脐部进针式镜,脐左（左侧疝）或脐右（右侧疝）进针式操作钳,于内环口体表投影处进雪撬针。体外打结,术中检查和／或治疗对侧可能存在的隐性疝。     

Laparoscopic adrenalectomy in children

PurposeReporting on the laparoscopic technique for adrenal disease in children and adolescents has been limited. We review here our experience with laparoscopic adrenal surgery in children.Patients and methods19 laparoscopic unilateral adrenalectomies were performed in 10 girls and 7 boys (mean age 3.9 years) during 1998–2011. The clinical diagnosis before surgery was virilizing tumor (n = 8), pheochromocytoma (n = 3), nonfunctioning solid adrenal tumor (n = 3), mixed adrenocortical tumor (n = 2), cystic adrenal mass (n = 1). Unilateral adrenal lesions were 20–65 mm at the longest axis on computerized tomography (12 right side, 7 left side).ResultsThe final clinicopathological diagnosis was cortical adenoma (n = 9), pheochromocytoma (n = 3, bilateral in two), neuroblastoma (n = 1), ganglioneuroblastoma (n = 1), ganglioneuroma (n = 1), adrenocortical carcinoma (n = 1), benign adrenal tissue (n = 1). Average operative time was 138.5 min (range 95–270). Blood transfusion was required in one case (5%). No conversion to open surgery was required and no deaths or postoperative complications occurred. Average hospital stay was 3.5 days (range 2–15). Average postoperative follow-up was 81 months (range 2–144). Two contralateral metachronic pheochromocytomas associated with von Hippel-Lindau syndrome occurred, treated with partial laparoscopic adrenalectomy (one without postoperative need of cortisone replacement therapy).ConclusionsLaparoscopic adrenalectomy is a feasible procedure that produces good results. It can be used safely to treat suspected benign and malignant adrenal masses in children with minimal morbidity and short hospital stay.     

Laparoscopic gastrostomy in children

During a 30-month period, 28 children aged 6 months-15 years underwent fashioning of a laparoscopic gastrostomy. Indications for operation included: feeding difficulties and failure to thrive in neurologically impaired children (13); chronic renal failure (9); and others (6). There were 17 conventional tube and 11 button gastrostomies. Twelve children had insertion of a gastrostomy alone; the others underwent a concomitant laparoscopic Nissen fundoplication (NFP). The average operation time for gastrostomy alone was 65 min (range 35–104) and for gastrostomy plus NFP 155 min (range 130–246). There were no specific laparoscopic complications. Two patients who required large volumes of eternal drugs and peritoneal dialysis from the 1st post-operative day developed minor external leaks from their stomas. It appears that laparoscopy provides for safe and precise positioning of any standard balloon or button gastrostomy. It is a particularly attractive technique for use in patients already undergoing a laparoscopic fundoplication and those in whom other minimally invasive techniques are contraindicated or fail.     

腹腔镜儿童脾切除术的若干问题

目的 结合病例就儿童腹腔镜脾切除术的一些问题进行讨论。方法2003年4月～2004年7月，上海新华医院儿童医学中心应用腹腔镜完成儿童脾切除术12例，其中，遗传性球形红细胞增多症6例，特发性血小板减少性紫癜（ITP）5例，脾血管瘤1例伴有血小板减少。12例均在腹腔镜下完成脾切除术。结果2例ITP于脾门部发现副脾，游离脾门前先行摘除。11例脾脏经10mm孔在取物袋内打碎后取出，1例脾过大无法装入取物袋经下腹皮纹切口取出。1例脾蒂游离中发生中等量出血300ml，给予输血300ml。1例在脾上极游离时伤及胃底，致胃穿孔，镜下修补满意。术后12例患儿恢复好，分别于手术后第5～11d出院。术后随访1～14个月，所有患儿生长发育好，血小板计数和贫血得到纠正。结论儿童腹腔镜下脾切除是一安全有效的技术，并发症的发生与学习曲线有关。手术指征的掌握、术中出血的预防和控制、副脾的切除与否及游离脾脏能否顺利取出是能否完成手术和影响预后的重要因素。