Laparoscopic surgery in infants and children.

Almost all operations that are classically performed as open surgery have now an endoscopic surgical variant. The reason for performing this form of surgery obeys the Hippocratic principle: The less invasive the better. Moreover there is scientific evidence that the less trauma, the less stress response and the less immunosuppression. There are few well conducted studies in children comparing open with endoscopic surgery, but evidence is piling up, especially from studies in adults, that endoscopic surgery results in a faster recovery, better cosmesis and fewer adhesions. The complication rate seems, however, slightly higher. Endoscopic surgery takes more time but hospital stay is shorter so that the same output can be achieved with fewer beds. Endoscopic surgery has changed the mentality of pediatric surgeons. Nowadays pediatric surgeons think more in terms of invasiveness which means that even in open surgery incisions are not as large anymore as they have been in the past. Endoscopic surgery has also changed the mentality in nursing. The wounds do not anymore reflect the magnitude of the surgery that has been performed internally, which may lead to an underestimation of pain. As the turnover of patients is much higher, there is less patient and parent binding. Lastly some parents may be overwhelmed by the rapid discharge and nurses have to guide them. Some nurses feel that the ward has become less surgical, which may have an impact on recruitment.     

Laparoscopic gastrostomy in infants and children.

Gastrostomy is a common procedure in children. Percutaneous endoscopic gastrostomy (PEG) is less traumatic than open surgery, but carries a higher risk in small children. We report our experience with laparoscopic gastrostomy, which appears to combine the advantages of the PEG and the safety of an open operation. Operative technique. An umbilical port (5 or 10 mm, depending on the patient's weight) and a left subcostal cannula (site of the future gastrostomy) are used. The stomach is pulled to the abdominal wall with two T-anchors, and the gastrostomy is performed using the Seldinger technique. A 17-Fr peel-away sheath is placed, through which a 5 mm endoscope is introduced to confirm its intragastric position. A 14-Fr balloon gastrostomy tube or button is then introduced. Results. Fifty-one children, aged 0 to 19 years (mean 4.4 +/- 6.4 years), underwent a total of 54 laparoscopic gastrostomies in a 42-month period. Thirty-three patients were younger than 2 years, and 22 weighed less than 5 kg. Thirty-three children had failure-to-thrive, 12 suffered from cerebral palsy and 8 from cystic fibrosis. Operative time was 33.6 +/- 14.3 minutes; in 18 cases, a concomitant Nissen fundoplication was performed (total operative time 76.5 +/- 58.7 minutes). In all cases, gastrostomy feedings were started the following day, and hospital stay in the gastrostomy-only group was 3.3 +/- 0.6 days. There were two (recognized) perforations of the back wall of the stomach, which were repaired laparoscopically, and two tube dislodgments, at 24 hours and at 4 months, requiring reoperation. Conclusions. Laparoscopy allows a quick and simple technique of gastrostomy placement under direct vision in even the smallest newborn and infant. It carries minimal operative risks and allows initiation of feedings within 24 hours.     

腹腔镜下Nissen和Toupet手术治疗小儿食管裂孔疝的近期疗效

目的 探讨腹腔镜手术治疗小儿食管裂孔疝的手术安全性和疗效.方法 2012年7月至2015年8月在腹腔镜下手术66例食管裂孔疝患儿,男41例,女25例;手术年龄1～39个月,平均(26±10)个月;体重3.2～16kg,平均(9.5±6.1)kg.所有病例术前均经消化道造影明确诊断;Ⅰ型疝(滑疝)25例,Ⅱ型疝(旁疝)37例,Ⅲ型疝(混合疝)2例,复发疝1例;手术采用腹腔镜3孔或4孔法,3-0prolene线缝合修补食管裂孔,固定食管于膈肌处,保留腹段食管3～4 cm,胃底折叠270°(Toupet) 32例或360°(Nissen) 34例.结果 所有病例均在腹腔镜下顺利完成手术,手术时间40～230 min,平均(70±25) min;术中出血2～10 mL,术后24～72 h进食,术后住院7～15 d,平均(11±2.6)d.术后随访1～37个月,出院1个月均行食管钡餐复查,未见明显疝孔形成,无呕吐症状,体重增加明显.结论 采用腹腔镜手术治疗儿童食管裂孔疝疗效好,恢复快,微创美观,安全可靠.随着手术经验的增加,开孔的数目由4孔减少为3孔,手术时间也与常规的开腹时间无明显差别.     

Follow-up imaging after laparoscopic heminephrectomy in children

BACKGROUND: The radiological findings after laparoscopic heminephrectomy in children are not widely reported. OBJECTIVE: To document the range of imaging appearances following laparoscopic heminephrectomy in children. MATERIALS AND METHODS: We reviewed all imaging and all radiology reports performed on children in our institution who had undergone laparoscopic heminephrectomy over a 6-year period. RESULTS: Between 2001 and 2007, 35 patients (24 girls, 11 boys) had laparoscopic heminephrectomy. The mean age at surgery was 3.5 years. The sites of surgery comprised 12 right upper, 5 right lower, 18 left upper and 3 left lower heminephrectomies. These numbers included three patients who had bilateral procedures. The most consistent postoperative finding was an avascular cyst related to the site of surgery, seen after 23 of 38 procedures. Of these 23 cysts, 13 were simple and 10 were septated and/or contained echogenic debris. CONCLUSION: A cyst related to the site of laparoscopic heminephrectomy is a frequent postoperative occurrence but is not widely recognized for being simply this. Simple, anechoic, and septated appearances are possible. This cyst may be confusing to the radiologist and the clinician if they are not aware of the history of laparoscopic heminephrectomy and the technique that has been used. Whilst the exact aetiology of this cystic lesion is uncertain, all the patients in our series had a heminephrectomy performed with the use of an Endoloop (Ethicon, Somerville, NJ). No patients have required intervention to date.     

Laparoscopic versus open inguinal herniotomy in infants and children: a meta-analysis

Purpose  

To undertake a meta-analysis of comparative data of laparoscopic versus open inguinal herniotomy in infants and children.     

Management of calculus anuria in children: Experience of 54 cases

ObjectiveTo evaluate the outcome of different treatment plans for calculus anuria in children.Patients and methodsPatients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine ≥ 3.5 mg/dl, blood urea ≥ 100 mg/dl, serum potassium ≥ 7 meq/l and/or blood pH ≤ 7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery.ResultsFifty-four patients were included. All patients regained normal serum creatinine levels within 72–120 h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent.ConclusionsUrinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery.     

小儿主动脉缩窄诊治及随访54例报告

目的　总结小儿主动脉缩窄 (COA)诊断和治疗中的经验教训。方法　收集 10年来 (1993年 6月至 2 0 0 3年 12月 )在广东省心血管病研究所确诊并接受了手术治疗的 5 4例 14岁以下COA病例 ,对一般临床资料、超声心动图、螺旋CT和选择性心血管造影结果、手术方法、随访结果和预后进行分析。结果　超声心动图漏诊或误诊 7例 ;住院期间死亡 5例 (9 2 6 % ) ,其中 4例为 1～ 6个月的婴儿 ,存活的 4 9例经 3个月到 7年的随访 ,治愈 4 5例。有 2例行左锁骨下动脉翻转术者 ,术后 1～ 2年证实再缩窄而再次手术。结论　在COA的诊断上 ,超声心动图仍有一定的局限性 ,对婴幼儿及危重患儿疑有COA而不宜进行心导管检查者可将螺旋CT检查作为首选。手术方式以端端吻合预后最好。术后主要死亡因素是合并其它心内复杂畸形及重度肺动脉高压。     

Management of the first nonfebrile seizure in infants and children

Seizures are the most common pediatric neurologic disorder. This article describes the guidelines of the French Pediatric Neurology Society, highlighting the importance of a thorough history and examination. Paroxysmal nonepileptic events should be excluded. The role of biological and neuroradiological investigations is discussed. An electroencephalographic recording and advice from a pediatric neurologist are suggested.     

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.     

HACEK endocarditis in infants and children: two cases and a literature review

We report 2 cases of Haemophilus parainfluenzae endocarditis and review 34 cases of HACEK endocarditis from the literature. HACEK organisms are the most common cause of Gram-negative endocarditis in children. They have a propensity to form friable vegetations (especially H. parainfluenzae) that break off and cause symptomatic emboli. HACEK endocarditis (from a review of the 36 published cases) may involve previously normal hearts (33%), may be complicated by embolization (31%) and may require vegetectomy or other surgery (31%). Mortality with HACEK endocarditis was 14%. HACEK organisms may be resistant to penicillins but are susceptible to third generation cephalosporins.     

Liver transplantation in infants and children. Evaluation of the first 40 cases (March 1991-March 1997)]

BACKGROUND: Liver transplantation (LT) is the treatment of end-stage liver disease in children. We report our experience with LT using grafts from living related (LRD) and cadaver donors (CD). POPULATION: From March 1991 to March 1997, 40 children and infants received a total of 42 liver grafts. A reduced-size liver was used in 28 cases. We studied pre-transplantation status, survival rate, and medical and surgical complications in these patients. RESULTS: The survival rate in our series was respectively 85 and 80% at 1 and 7 years after LT. Low weight infants required a prolonged ventilatory assistance. Five of the six deaths noticed during the first three months after LT occurred in children weighing less than 12 kg. One year after LT, no significant difference in the incidence of rejection was found, neither between low-weight children and the others, nor between patients transplanted from CD or LRD. Biliary tract stricture was the major surgical complication. CONCLUSION: This series consisted of a majority of low-weight children. The survival rate in the patients weighting less than 12 kg is lower than in the others. This may be explained by the nutritional status of these patients and early postsurgical complications. The use of grafts from living donors offers more flexibility since the operation is performed electively, but it did not seem to modify the incidence of acute rejections and surgical complications.     

Penoplasty for buried penis in infants and children: report of 100 cases

Purpose  The aim of this study is to report single surgeon’s experience in treatment of buried penis in children and describe the surgical technique which was developed by the senior author. Methods  Described surgical technique avoids circumferential incision at the base of the penis and thus prevents formation of post-operative lymphedema. Repair is based on a vertical incision in median raphe, complete degloving of penis and tacking its base to prepubic fascia. Shaft skin is attached to base of penis with vertical mattress sutures. Results  Patient age varied from 1 month to 11.4 years (mean 1.9 years). All patients had good to excellent outcome with uniformly improved visualization of penile shaft post-operatively. There was one case of wound infection successfully treated with oral antibiotics. Revisions were needed in 4% patients. Conclusion  Surgical correction of buried penis in infants and children is safe and effective. Described technique is applicable for essentially all cases of congenital buried penis as well as for iatrogenically entrapped penis after circumcision. In our experience there were no additional procedures required to assure skin coverage of penile shaft. An erratum to this article can be found at     

Scorpion sting in children in the Jerusalem area: a review of 54 cases.

Fifty-four children from the Jerusalem area were studied prospectively following scorpion envenoming. Their ages ranged from 11 months to 10 years. Severe symptoms (convulsions, brain oedema, shock, respiratory distress and myocarditis) were encountered in 19. Respiratory distress was the main feature in 17 of the children, in two cases owing to pulmonary oedema and in a third because of adult respiratory distress syndrome and myocarditis; mechanical ventilation was required in three cases. The severity of the symptoms and signs was not related to sex, age, weight, interval between scorpion sting and admission or to the type of offending scorpion; it was most likely dependent upon the susceptibility of the individual and/or the dose of venom injected by the scorpion. Intravenous antivenom quickly reversed the symptoms, and no side-effects were seen in the patients studied. The two patients who died had not received the antivenom intravenously. We recommend that specific antivenom should be given intravenously in all children who show significant symptoms. Furthermore, a longer period of observation is necessary following scorpion sting in this age group.