Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery.

BACKGROUND: Laparoscopic surgery has reduced the length of hospital stay for common operations like cholecystectomy, gastric fundoplication, and appendectomy. We have noticed a reduction in length of hospital stay for children undergoing laparoscopic appendectomy. We, therefore, looked at our data to assess whether laparoscopic appendectomy in children could be performed as fast-track or same-day surgery (< or = 24-hour postoperative stay). METHODS: We performed a retrospective review of the records of all children who underwent laparoscopic appendectomy for suspected appendicitis during a 3-year period (7/97 to 7/00). RESULTS: Laparoscopic appendectomy was performed in 79 children (44 boys and 35 girls), between 2 to 17 years of age (mean, 11 years). In 4 (5%) children with perforated appendicitis, the laparoscopic appendectomy was converted to an open appendectomy. At operation, 51 (64.5%) had acute appendicitis, 22 (27.8%) had perforated appendicitis, 4 (5%) had ruptured ovarian cysts, and 2 (2.5%) had no pathology. The median operative time was 54 minutes. Total length of stay for all 79 patients was a median of 58 hours, and median postoperative LOS was 35 hours. Complications included wound infection (2), abdominal abscess (4), drug rash (2), and epididymo-orchitis (1). In 57 (72%) children without perforated appendicitis, the total length of hospital stay was a median of 42 hours, while median postoperative length of stay was only 28 hours. Thirty-two (56%) children went home in < or = 24 hours following laparoscopic appendectomy. No significant morbidity was noted in the nonperforated group (drug rash, 1 fever > 24 hrs, 3); and no readmissions or reoperations were necessary on follow-up. CONCLUSION: Laparoscopic appendectomy is safe and effective for treating children with appendicitis. Laparoscopic appendectomy may be safely performed as fast-track or same-day surgery, in select children without perforated appendicitis, with a postoperative stay of < or = 24 hours.     

Clinico‐pathological spectrum of gallbladder disease in children

Aim: Because of wide variation in clinico‐pathological spectrum of gallbladder disease in children the world over, the data of gallbladder disease from this stone belt of India were analysed. Methods: Children who underwent cholecystectomy over a period of 8 years January 2002–December 2009 were reviewed. Results: Out of 7076 cholecystectomies, 56 (0.79%) were in children. Thirty‐nine (69.6%) children were 11–16 years of age. Thirty‐seven (66.07%) children were girls and nineteen (33.9%) were boys. In 12 (21.4%) children, cholecystitis was acalculus. Five (8.9%) children had associated haemolytic disease and 4 (7.1%) children had congenital anomaly in the form of choledochal cyst. Ultrasound findings were available in 44 cases and showed cholelithiasis in 36 cases. Twenty‐two (39.3%) children had mixed cholelithiasis, 8 (14.2%) pigment cholelithiasis, 10 (17.8%) combined cholelithiasis and 4 (7.1%) patients had small concretions. Microscopically, changes of chronic cholecystitis were seen in 98.2% while 1.7% showed acute on chronic cholecystitis. There was single unusual case of cysticercus in the wall of the gallbladder. Conclusions: The frequency of gallstone disease is 0.79%. Nonhaemolytic type of cholelithiasis is more common than haemolytic type in this region. Presence of cysticercus in the gallbladder wall in one case was an unexpected finding.     

Ruptured supratentorial dermoid cysts

Two cases with ruptured supratentorial dermoid cysts are presented. Computerised tomography and magnetic resonance findings are illustrated. The pathology and differential diagnosis is discussed.     

The efficacy and safety of armodafinil as treatment for adults with excessive sleepiness associated with narcolepsy

OBJECTIVE: This study assessed the efficacy and safety of armodafinil, the longer half-life enantiomer of modafinil, for the treatment of excessive sleepiness in patients with narcolepsy. RESEARCH DESIGN AND METHODS: This was a multicenter double-blind study with 196 patients (aged 18-65 years) randomized to receive armodafinil 150 mg (n = 65), armodafinil 250 mg (n = 67), or placebo (n = 64) once daily for 12 weeks. MAIN OUTCOME MEASURES: Efficacy was assessed using the Maintenance of Wakefulness Test (MWT) (six 20-min subtests across the day), the Clinical Global Impression of Change (CGI-C), subjective measures of sleepiness (Epworth Sleepiness Scale), patient diaries, and evaluations of cognitive performance (Cognitive Drug Research) and fatigue (Brief Fatigue Inventory). RESULTS: Armodafinil significantly increased MWT mean sleep latency (at 0900-1500) compared with placebo. The mean change from baseline at final visit for armodafinil was an increase of 1.3, 2.6, and 1.9 min in the 150-mg, 250-mg, and combined groups, respectively, compared with a decrease of 1.9 min for placebo (p < 0.01 for all three comparisons). Mean late-day MWT latency (1500-1900) was also significantly improved (difference of armodafinil combined group relative to placebo at final visit: 2.8 min, p = 0.0358). The proportions of patients who showed at least minimal improvement in the CGIC rating from baseline to final visit in the armodafinil 150-mg, 250-mg, and combined groups were 69%, 73%, and 71%, respectively, compared with 33% for placebo (p < 0.0001). Both doses were associated with statistically significant improvements in memory, attention, and fatigue (p < 0.05). The most common adverse events in patients receiving armodafinil were headache, nausea, and dizziness. CONCLUSIONS: Armodafinil significantly improved ability to sustain wakefulness throughout the day in patients with narcolepsy. Armodafinil also significantly improved overall clinical condition, memory, attention, and fatigue when compared with placebo.     

Thoracoscopic ligation of the thoracic duct in a child with spontaneous chylothorax

We report a case of a 2-year old girl with a spontaneous chylothorax who presented with respiratory distress. The management of this condition, which included thoracic duct ligation using a thoracoscopic technique, is discussed, and we review the literature on chylothorax.     

Laser conjunctivoplasty: A new technique for correction of mild medial ectropion

Thirty patients with mild medial ectropion of the lower lid were treated by Argon green laser.A diamond-shaped area (6 × 4mm in size) on the medial part of the tarsal conjunctiva of the lower lid was burnt with overlapping spots until white blanching and visible contraction of tissue were seen. The apex of the diamond was kept 4mm below the punctal opening. After an average follow-up of 6 months, functional success was achieved in 22/30 eyes. Anatomical success in terms of repositioning of the punctum was attained in 24/30 eyes. The only side effect noted was a mild burning sensation of the eyes lasting for two hours after the procedure. This is the authors’ initial experience with a somewhat new and easy procedure to treat mild medial ectropion of the lower lid that can be performed on an outpatient basis.