Supplementation of retrobulbar block with clonidine in vitreoretinal surgery: effect on postoperative pain

Study Objective

To evaluate the effect of clonidine when added to local anesthetics on duration of postoperative analgesia during retrobulbar block.

Design

Prospective, randomized controlled trial.

Setting

Operating room and Postanesthesia Care Unit of a university-affiliated hospital.

Subjects

80 ASA physical status 1, 2, and 3 patients undergoing vitreoretinal surgery with or without scleral buckling.

Interventions

Patients in the control group (n = 40) received a retrobulbar block with 4.5 mL of lidocaine-bupivacaine and 0.5 mL of saline. Clonidine group patients (n = 40) received 4.5 mL of lidocaine-bupivacaine and 0.5 μg/kg of clonidine in a 0.5 mL volume.

Measurements

The time to first analgesic request, frequency of postoperative pain, and number of postoperative analgesic requests per patient were assessed.

Main Results

37 patients in the control group (92.5%) versus 24 patients (60%) in the clonidine group reported pain postoperatively (P = 0.001), with a shorter time to first analgesic request noted in the control group (4.9 ± 3 vs 11.9 ± 5.3 hrs; P < 0.001). The median number of postoperative analgesic requests per patient during the first 24 hours was higher in the control group than the clonidine group [2 (0-3) vs. 1 (0-3); P < 0.001].

Conclusions

The addition of clonidine 0.5 μg/kg to the local anesthetics of a retrobulbar block for vitreoretinal surgery decreases the frequency of postoperative pain and prolongs the time of analgesia.     

Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging condition

Background

Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy.

Methods

In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared.

Results

The success rate was 100% in the study group compared with 30% in the control patients.

Conclusions

Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.     

Fragmented international volunteerism: need for a global pediatric surgery network

Introduction

Pediatric general surgeons volunteering internationally often work independently, some without prior assessment of the needs of those they wish to assist. Consequently, care may be inefficient, duplicated, or misdirected. A study was performed to assess whether a network for pediatric surgery volunteer work exists.

Methods

A search of the Internet was performed to determine whether a pediatric surgery network exists. Worldwide pediatric surgery societies were identified and grouped by country according to income. Web sites for medical volunteer organizations were examined for links to a network of pediatric surgery volunteer work.

Results

A search of the Internet revealed no pediatric surgery volunteer network. Ninety-seven pediatric surgery societies were identified. Fifty-one of the organizations were identified as residing in low- and middle-income countries. Searching 50 Web sites for these societies revealed no existing pediatric surgery network. Of 45 Web sites for volunteer medical work, 1 surgery networking Web site was identified. Only 4 pediatric general surgery international volunteer opportunities were cited on that Web site.

Conclusions

This study demonstrated that no pediatric surgery volunteer network exists. By identifying pediatric surgery organizations in low- and middle-income countries, it is speculated that one might link the surgeons in these regions with those wishing to volunteer their services.     

Cholangitis as a late complication in long-term survivors after surgery for biliary atresia

Background/purpose

A retrospective review was performed to assess the utility of diagnostic imaging (DI), efficacy of treatment, and outcome of late cholangitis in long-term survivors after surgery for biliary atresia.

Methods

Sixty-one patients surviving without liver transplantation (LTx) for more than 20 years were divided into 2 groups depending on whether cholangitis developed after age 20. Clinical factors including the type of obstruction, the age at the initial operation, and the early complication with cholangitis were compared between the 2 groups. DI such as computed tomography scan and magnetic resonance imaging, clinical courses after treatment of cholangitis, and current status of the patients were also evaluated.

Results

Thirteen patients had cholangitis after age 20. There was no statistical difference in the clinical factors studied between the 2 groups. Abnormal DI findings including dilatation of intrahepatic bile ducts and hepatic fibrosis were seen in 10 patients with late cholangitis. One patient died, and 2 ultimately underwent LTx. The remaining 10 patients including 4 with normal or near-normal liver function have survived without LTx.

Conclusions

Although the majority of the patients had potential predisposing factors for cholangitis such as dilatation of intrahepatic bile ducts, a few patients unexpectedly had cholangitis without such abnormal findings after an excellent, long-term postoperative course.     

Management of duodenal injuries in children

Background/purpose

The natural history and management of pediatric duodenal injuries are incompletely described. This study sought to review injury mechanism, surgical management, and outcomes from a collected series of pediatric duodenal injuries.

Methods

A retrospective chart review was conducted for a 10-year period of all children less than 18 years old treated for duodenal injuries at 2 pediatric trauma centers.

Results

Forty-two children were treated for duodenal injuries. There were 33 blunt and 9 penetrating injuries. Injuries were classified using the Organ Injury Scale for the Duodenum. Twenty-four patients underwent operative management by primary repair (18), duodenal resection and gastrojejunostomy (4), or pyloric exclusion (2). Duodenal hematomas were treated nonoperatively in 94% of cases. The average ISS for operative versus nonoperative cases was 23 and 10, respectively. Delay in diagnosis or operative intervention (>24 hours) was associated with increased complication rate (43% v 29%) and hospitalization (32 v 20 days). Nine children requiring surgery experienced delays and were most highly associated with foreign body, child abuse, and bicycle injuries. There were no deaths caused by duodenal injuries.

Conclusions

Duodenal injuries in children were predominantly blunt and had a low mortality rate. When surgery was required, primary repair was usually feasible.     

Laparoscopy-assisted transanal pull-through at the time of suction rectal biopsy: a new approach to treating selected cases of Hirschsprung disease

Aim

We present a new approach to treating selected cases of Hirschsprung disease (HD) where suction rectal biopsy (SRBx) is performed in an operating room, and rapid acetylcholinesterase staining (RAST) is used to identify histopathology within 20 minutes, allowing primary laparoscopy-assisted transanal pull-through (PLTPT) to be commenced “immediately” (n = 7).

Materials and Methods

All subjects had an obvious caliber change in the rectum/sigmoid colon on barium enema and were strongly suspected of having HD.

Results

Rapid acetylcholinesterase staining clearly demonstrated acetylcholinesterase-positive hypertrophic nerve trunks and absence of ganglion cells in all SRBx specimens, indicating that all 7 patients had HD. All 7 proceeded to uneventful PLTPT. By taking this approach, SRBx results were available extremely quickly, and hospital stay was reduced by 2 to 4 days.

Discussion

Our approach enhanced the treatment of selected cases of HD by proceeding immediately to PLTPT after SRBx specimens were examined using RAST.     

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction

Introduction

Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH.

Methods

From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively.

Results

Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure.

Conclusion

CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.     

Accuracy of ultrasonography and mammography in predicting pathologic response after neoadjuvant chemotherapy for breast cancer

Background

Neoadjuvant chemotherapy reduces tumor size before surgery in women with breast cancer. The aim of this study was to assess the ability of mammography and ultrasound to predict residual tumor size following neoadjuvant chemotherapy.

Methods

In a retrospective review of consecutive breast cancer patients treated with neoadjuvant chemotherapy, residual tumor size estimated by diagnostic imaging was compared with residual tumor size determined by surgical pathology.

Results

One hundred ninety-two patients with 196 primary breast cancers were studied. Of 104 tumors evaluated by both imaging modalities, ultrasound was able to size 91.3%, and mammography was able to size only 51.9% (χ²P < .001). Ultrasound also was more accurate than mammography in estimating residual tumor size (62 of 104 [59.6%] vs 33 of 104 [31.7%], P < .001). There was little difference in the ability of mammography and ultrasound to predict pathologic complete response (receiver operating characteristic, 0.741 vs 0.784).

Conclusions

Breast ultrasound was more accurate than mammography in predicting residual tumor size following neoadjuvant chemotherapy. The likelihood of a complete pathologic response was 80% when both imaging modalities demonstrated no residual disease.     

Four-triangular-skin-flap approach to umbilical diseases and laparoscopic umbilical port

Background/purpose

Surgery of umbilical pathology requires restoration of a normal umbilical appearance. Also, the umbilicus is used increasingly as the entry site during laparoscopic surgery. However, conventional approaches leave obvious scars. A simple alternative approach that creates a natural-looking umbilicus is described.

Methods

The umbilicus is opened by creating 4 isosceles triangular skin flaps. Closure is by suture of the flap apex only, creating scaring that resembles a natural umbilicus.

Results

Between November 1996 and March 2003, this technique was used in 204 children with umbilical hernia, 2 children with a small omphalocele, 1 child with a patent omphalomesenteric duct, 2 children with a urachal abscess, and 7 children with an umbilical granuloma. Five children underwent initial trocar insertion during laparoscopic surgery via this approach. All procedures were performed uneventfully. Transient erythema of one flap occurred in 64 patients (29.2%). Infection developed in 10 patients (5.0%) but was treated with oral antibiotics. The postoperative umbilical appearance was satisfactory in all but 5 patients.

Conclusions

The 4-triangular-skin-flap approach is useful for umbilical diseases and laparoscopic umbilical port access.     

Avoiding misdiagnosing neuroblastoma as Wilms tumor

Purpose

Although occasionally difficult, distinguishing abdominal neuroblastoma (NBL) from Wilms tumor (WT) at presentation is important, as surgical management differs significantly. We reviewed our 20-year experience (1987-2006) treating patients with NBL, focusing on those with an initial diagnosis of WT, to determine presenting features that would have suggested the correct preoperative diagnosis.

Methods

Retrospective case cohort study reviewing charts and imaging of patients with NBL initially diagnosed clinically with WT. Preoperative symptoms, laboratory studies, and imaging were evaluated. Similar variables were assessed in the 20 patients with WT most recently treated at our institution.

Results

Nine patients with NBL were identified as those who had an exploratory laparotomy with a preoperative diagnosis of WT; 8 underwent nephrectomy at exploration. Children with NBL had symptoms such as fever and weight loss at presentation (67%) more often than patients with WT (20%). Preoperative computed tomography demonstrated intratumoral calcifications, vascular encasement, or both in 78% of patients with NBL but were never seen in WT patients. Of interest, preoperative urinary catecholamines were elevated in 5 patients ultimately diagnosed with NBL.

Conclusion

Although NBL can be mistaken for WT at presentation, the presence of constitutional symptoms, or intratumoral calcification or vascular encasement on preoperative imaging should heighten suspicion for NBL. In addition, laboratory evaluation, including urinary catecholamines, should be completed before surgery when the etiology of an abdominal tumor is uncertain.     

A prospective study comparing operative time in conventional laparoscopic and robotically assisted Thal semifundoplication in children

Background

It is not clear if robotically assisted surgery (providing articulating instruments, 3-dimensional vision, intuitive ergonomics) performed in pediatric patients offers the same advantages over conventional surgery as in adult patients. In the laboratory setting, robots require less time to perform certain tasks. Accordingly, we tested the hypothesis that the time required to perform a robotically assisted laparoscopic Thal semifundoplication is different compared with a conventional laparoscopic procedure in children.

Methods

The time required to perform single operative steps was prospectively recorded in 10 consecutively performed Thal semifundoplications with the use of a robot (da Vinci) and in 10 consecutively performed operations done by conventional laparoscopy.

Results

No conversion to an open operation was necessary, and there were no intraoperative complications throughout the study and no postoperative complications up to 14 months after surgery. Total operative time was similar in both groups. In the robotically assisted group, time for setup was significantly longer (20.8 ± 7.5 vs 34.6 ± 9.2 minutes, P < .05), but dissection of the hiatal region as the most challenging operative step was accomplished 34% faster in the robotically assisted group (30.8 ± 8.7 vs 20.2 ± 5.3 minutes, P < .05).

Conclusion

At the current level of technology, the robotic system is superior compared with established standard laparoscopic techniques requiring tissue preparation; however, the potential benefit in operating time is counterbalanced by the increased complexity of setting up the system.     

Mortality and morbidity of patients with neuroblastoma who survived for more than 10 years after treatment—Niigata Tumor Board Study

Purpose

To evaluate the utility of treatment strategies in neuroblastoma (NB), the survival of the NB patients was retrospectively examined.

Methods

During the past 40 years from 1967 to 2006, 103 NB patients not detected by the mass screening program were treated. The patients were divided into 3 groups; the period of aggressive surgery (AS group: 43 patients) from 1967 to 1984, the period of aggressive chemotherapy (AC group: 40 patients), from 1985 to 1996, and the period of mega-chemotherapy with stem cell transplantation since 1997. The patients treated in the AC and the AS groups were examined.

Results

The survival curve reached a nadir within 3 years in the AS group, whereas the second major drop of the survival curve was found in the AC group, which was owing to late mortality of 7 patients more than 10 years after the initiation of treatment. As a result, the overall survival in the AS and the AC groups were approximately 30.2% and 30.0% at 20 years after treatment, respectively. A different kind of strategy-related morbidity was found in 46% of EFS in both the AS and the AC groups.

Conclusions

The effectiveness of a treatment strategy should therefore be assessed after several decades.     

A novel corrective pullthrough surgery in a mouse model of Hirschsprung's disease

Background/Purpose

The study aimed to develop a mouse model of post-pullthrough Hirschsprung's disease that will allow investigation of mechanisms that cause postoperative complications.

Methods

We developed a novel microsurgical pullthrough operation on Balb/C mice and evaluated its effect on growth rate and stooling pattern. Histologic assessment of the pullthrough colon was performed. The pullthrough operation was then performed on Ednrb−/− mice that have aganglionic megacolon and Ednrb+/+ littermate controls, and the outcomes compared.

Results

The Balb/C pullthrough group had 97% survival at 1 week and 70% survival at 2 weeks. Body weight of the pullthrough animals declined 15% in the first week after surgery and subsequently normalized. The stooling pattern showed consistently softer stools in the pullthrough group, but no difference in frequency compared to controls. Histopathologic analyses 4 weeks postoperatively showed well-healed coloanal anastomoses. Two-week survival after pullthrough surgery in Ednrb−/− and Ednrb+/+ mice was 50.0%, and 69.2%, respectively (P = NS). Increased mortality in the Ednrb−/− mice was related to the technical challenge of performing microsurgery on smaller-sized mice with poor baseline health status.

Conclusions

Our microsurgical pullthrough operation in mice is feasible and allows systematic investigations into potential mechanisms mediating post-pullthrough complications and poor long-term results in mouse models of Hirschsprung's disease.     

Approaches to neurodevelopmental assessment in congenital diaphragmatic hernia survivors

Background

Infants with congenital diaphragmatic hernia require complex surgical care and may have neurodevelopmental morbidity. We examined the performance of reports of motor functioning in 25 congenital diaphragmatic hernia survivors using the parent-completed Developmental Profile-II and a clinical evaluation by a neurodevelopmental pediatrician (MD) measured against the Bayley motor scale.

Methods

Bayley motor scores were dichotomized as normal or abnormal. Sensitivity and specificity were calculated for each test.

Results

The median age at assessment was 25 months. Bayley motor scores were abnormal in 77% of infants tested (10/13). The MD examinations detected motor problems in 92% (12/13). Sensitivity and specificity of the MD examination were 1.0 and 0.33, respectively. Developmental Profile-II physical scores were abnormal in 15% (2/13); sensitivity and specificity were 0.2 and 1.0, respectively.

Conclusions

The high rate of abnormal motor findings in this study supports the need for ongoing screening and evaluation. The sensitivity of MD examinations was excellent, but hypotonia findings were not universally corroborated by the Bayley. Although specificity of parent-reported motor findings was high, parents underreported abnormal motor findings. Parental reports of neurodevelopmental problems should be heeded, and physicians should perform screening motor examinations. Bayley assessments may be warranted to determine the functional implications of observed abnormalities.     

Complex vascular reconstruction of abdominal aorta and its branches in the pediatric population

Background

Subdiaphragmatic aortic diseases in children are rare and form a heterogeneous group. The pediatric patient presents unique challenges because of their size, concerns about proper timing and conduit for repair, and anticipating expected growth.

Methods

We performed a retrospective review of operations involving the abdominal aorta and called branches in children between January 2003 and April 2007, focusing on the details of preoperative evaluation, operative technique, and outcomes. The pertinent literature is reviewed.

Results

Twenty-two children (age, 2 days to 17 years) were included. Mean follow-up was 28 months. Aneurysms were seen in 5 children; the remainder had stenotic disease. Aneurysms were typically asymptomatic and diagnosed incidentally, whereas stenotic lesions most commonly presented with hypertension (HTN). Fourteen complex vascular repairs were performed. All of the children with aneurysms underwent prompt surgery. The children with stenoses had operations for poorly controlled HTN, claudication, and/or mesenteric ischemia. Most patients with stenotic disease were treated medically for HTN and were followed closely while awaiting optimal size and availability of autogenous conduit for reconstruction. Cryopreserved allograft was used in 3 of the aneurysm operations. Dacron grafts were used to repair 5 aortic stenotic lesions. Renal and mesenteric revascularizations were performed with saphenous vein grafts. Pediatric, general, and transplant surgeons and nephrologic and cardiologic teams were integral to evaluation and management. No major operative complications occurred.

Conclusion

Proper management of pediatric aortic vascular disease requires a multidisciplinary approach. It is best to use autologous grafts whenever possible. Children with stenotic disease should be treated medically for hypertension until they are large enough for an autologous graft reconstruction. Children with aneurysmal disease are at risk for embolism and thrombosis and therefore usually treated immediately using artificial graft material, if necessary.     

Margin assessment after neoadjuvant chemotherapy in invasive lobular cancer

Background

Optimal surgical management of patients with invasive lobular carcinoma (ILC) who undergo neoadjuvant chemotherapy (NAC) is unknown. We evaluated optimal margin distance and local recurrence (LR) rates for these patients.

Methods

Ninety-three (30%) of 311 patients with ILC received NAC. We examined margin status, residual disease after re-excision, and clinical outcomes.

Results

Margin positivity rates after the final operative procedure were similar between the NAC and surgery-first group (P > .05). The proportion of patients, stratified by margin status, who were taken back for re-excision was not different between the 2 groups, and, similarly, there were no differences in frequency of residual disease (all P > .05). At a median follow-up of 3.1 years, 1 patient in the NAC group and 2 in the surgery-first group developed LR (P = 1.0).

Conclusions

Patients with ILC who have undergone NAC and have margins >1 mm have a low probability of residual disease and LR.     

Chronic inflammation in congenital cystic adenomatoid malformations. An underestimated risk factor?

Purpose

Congenital cystic malformations of the lung are more frequently diagnosed before birth, but guidelines for surgical management of asymptomatic cases are lacking. The aim of this article is to review our 10-year results with antenatally diagnosed congenital cystic adenomatoid malformations (CCAMs) to debate indications for early postnatal surgical management in asymptomatic patients.

Method

Twenty-four cases were reviewed; of these, 18 were operated on before 15 days of life for respiratory distress or mediastinal shift, whereas 6 were submitted to elective surgery at 3 months of age.

Results

Twenty lobectomies and 4 atypical resections were performed. Two of the latter required a second surgery for incomplete primary perinatal resection. No postsurgical complications were reported. Nineteen (19/24) of the resected specimens showed signs of chronic inflammation. In the perinatal period, 100% (8 cases) of CCAM type II and 50% (8 cases) of CCAM type I resulted to be inflamed. Of the asymptomatic cases, 50% (3/6) were also found to be affected. No infections were detected at bacteriologic culture and bacterial debris was stained in 3 specimens.

Conclusion

In this series, a 79% incidence of pulmonary inflammation was detected. The CCAM type II resulted to be always involved in this process of inflammation. This was an unexpected finding, particularly in cases without mediastinal shift or respiratory distress. In light of these results, early postnatal treatment, at around 3 to 6 months of age, could be considered even in asymptomatic patients.