Timing of surgery for common pediatric surgical conditions

Depending upon various factors the surgical procedures in childhood are divided into three groups—immediate, intermediate and elective. The timing of surgery is probably the most important factor governing the outcome of surgical correction in pediatric surgery. With continuing research and clinical experience our understanding of the various conditions have improved and with that has come a change in the optimum timing of many surgical procedures. This paper highlights the best timing of surgery for some of the commoner pediatric surgical procedures and the reasons behind these so that the children may be referred to pediatric surgeons in time.     

Laparoscopic transgastric suturing for bleeding peptic ulcers

Background: Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing. Methods: After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a lift and cut technique. Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots. Results: Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm³/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement. Conclusions: It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Laparoscopic rectopexy for complete rectal prolapse

Background: The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations. Methods: Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography. Results: No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p=0.005) and the rectoanal inhibitory reflex improved in seven patients (p=0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p=0.02). Conclusions: Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures

Background: The objective of this preliminary study was to describe the particles contained in cautery smoke produced during five laparoscopic procedures and verify the collection method during three laboratory experiments on ex vivo animal tissue. Methods: A cascade impactor collected the smoke according to particle size, and particle weights were calculated on an electronic microbalance. Electron microscopic analysis and energy dispersive X-ray evaluation were used to determine particle morphology and elemental composition. Results: The particles, distributed according to size on the seven rotating trays of the impactor, had diameters ranging from 0.05 to >25 m, with most being 0.1–1 m. In vitro experiments yielded more particles, especially larger (>5 m) ones, than the surgical procedures, because the cauterized specimens could be placed much closer to the cascade impactor in the laboratory environment, eliminating most obstacles to particle recovery. In the laparoscopic surgery patients, larger particles, because of their physical properties, were more likely to remain trapped in the abdomen or to drop off in the collection apparatus. Uniformly, two populations of particles were demonstrated—either large, irregular fragments (2–25 m) rich in carbon and oxygen, suggesting structural cellular components, or small homogeneous spheres (0.1–0.5 m) composed of sodium, magnesium, calcium, and potassium salts. Conclusions: This study demonstrates the presence of breathable areosols and cell-size fragments in the cautery smoke produced during laparoscopic procedures. Their exact chemical composition and potential adverse effects for patients and personnel are not known.     

Increased incidence of retching and vomiting during periovulatory phase after middle ear surgery

Purpose  

To assess the effect of the menstrual cycle on post-operative retching and vomiting (R& V) after middle ear surgery, and the efficacy of prophylaxis against R& V in female patients with transdermal scopolamine during either general or local anaesthesia and with intravenous ondansetron during general anaesthesia.     

Therapeutic Megalipoextraction or Megaliposculpture

Background: For a long time, surgeons hesitated to extract more than 2.5 liters of adipose tissue from a patient. Through the years, liposuction has advanced, now allowing megaliposculptures to be performed so that more than 10 liters can be extracted without posing any greater risk to the patient than a conventional esthetic liposculpture. Methods: This article traces the progressive evolution of the technique, discussing complications and the concept of megaliposculpturing. Results: The syringe-assisted extraction of large quantities of adipose tissue without transfusion, hypovolemic shock, or any major complication opens new horizons in the symptomatic treatment of certain types of osteoarthritis of the lower extremities and the potential complications of obesity. Conclusions: Large quantities of adipose tissue may safely, quickly and efficiently be extracted. Numerous investigations in various pathological domains can now begin after this first step (megalipotherapy). Therapeutic megalipoextraction can be done either as a preliminary indication or as a treatment of the residual adiposities that occur after bariatric operations.     

Obesity: The Last Bastion of Prejudice

Background: Most people do not realize how pre-judicially damaging they behave, particularly towards the obese. Their discrimination has been deemed, unconsciously perhaps, as acceptable by society. Methods: This paper describes a high school senior's exploration of prejudice and discrimination towards the obese. Results: Through interviews with bariatric surgeons, bariatric patients, an obese victim of prejudice in her high school, attendance at support group meetings, statements from others experiencing similar bias in their workplace as well as a review of the relevant literature, the author developed a new understanding of the extent and depth of prejudice against the obese in North American society. She realized how this prejudice limits social opportunities and access of all sorts, interferes with employment opportunities, and even how deeply it penetrates the medical community. Conclusion: The intent of this paper is to educate those in society who continue to discriminate against the obese, and to open our eyes to our own behavior, as the author's have been opened.     

Drug Distribution in Obesity and following Bariatric Surgery: A Literature Review

Background: The pharmacokinetic variables of drug clearance and volume of distribution are usually corrected for body weight or surface area. Only recently have the relationships which exist between body size, physiologic function and pharmacokinetic variables been evaluated in the obese population. These effects are not widely known, and data on this and the effects of bariatric surgical procedures are scantily documented in the surgical literature. Methods: Literature review. Results: Drugs with a low or moderate affinity for adipose tissue have a moderate increase in the volume of distribution (Vd), and this correlates with the increase in lean body mass (LBM). Highly lipophilic drugs, with some exceptions, show the expected increase in Vd and prolongation of elimination half-life, indicating a marked distribution into adipose tissue. Drug absorption, in general, is slowed by delayed gastric emptying and is normal when gastric emptying is normal or increased. Most drug absorption occurs in the small intestine where duration of drug/mucosal contact is the most important factor. Conclusions: Drugs whose distribution is restricted to LBM should utilize a loading dose based on ideal body weight (IBW). For those drugs which distribute freely into adipose tissue, the loading dose should be based on total body weight (TBW). Adjustment of the maintenance dose depends on clearance rates. In a few cases dosage adjustment depends on pharmacodynamic data, since drug clearance does not conform to these recommendations, for reasons which remain to be defined. Following bariatric surgery, in the absence of delayed gastric emptying or uncontrolled diarrhea, drug absorption rates are usually comparable to the non-operated patient.     

Einfluß der orthograden darmspülung mit Prepacol® und Polyäthylenglykollösung auf die dauer des postoperativen Ileus nach kolorektalen resektionen

Zusammenfassung In einer prospektiv randomisierten Studie wurden bei 100 Patienten mit elektiven konventionellen (n=66) oder laparoskopischen (n=34) kolorektalen Resektionen die präoperative Darmvorbereitung mit einer 2 1-Polyäthylenglykol(PEG)-haltigen Lösung plus Prepacol® (Gruppe A, n=50) und die mit einer 4 1-PEG-Lösung (Gruppe B, n=50) verglichen. Im Rahmen der Studie wurde auch der Einfluß der Art und Qualität der Darmvorbereitung auf die Dauer des postoperativen Ileus untersucht. Die Qualität der Darmvorbereitung wurde wührend der Resektion am eröffneten Darm mit einem 4-Punkte-Score durch den Chirurgen bestimmt. Das Zeitintervall vom Ende der Operation bis zum ersten postoperativen Windabgang und dem ersten Stuhlgang wurden dokumentiert. Die Qualität der Darmvorbereitung wurde in beiden Gruppen als gleich gut beurteilt (Gruppe A: 94%; Gruppe B: 84%; p=0,5). Das postoperative Intervall bis zum Abgang von Winden (A: 3,1 ± 1,2 Tage; B: 3,2 ± 13 Tage; p = 0,6) und zum ersten Stuhlgang (A: 3,9 ± 1,3 Tage; B: 4,1 ± 1,3 Tage; p=0,5) war in beiden Patientengruppen etwa gleich lang. Als einziger Faktor mit eigenständigem Einfluß auf die Dauer des postoperativen Ileus in der multivariaten Analyse (Alter, Geschlecht, Vorbereitung, Operationsdauer, Operation, Operationstechnik) wurde die Operationstechnik (laparoskopisch oder konventionell) identifiziert. Der erste Stuhlgang trat nach laparoskopischeu Resektionen bereits nach durchschnittlich 3,2±1,1 Tagen auf, nach konventionellen Operationen dagegen erst nach 4,3±1,2 Tagen (p=0,001). Die Art (41 PEG oder 21 FEG plus Prepacol®) und Qualität der Darmvorbereitung beeinflußten die Dauer der postoperativen Motilitätsstörung nicht.

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Effect of bowel lavage with prepacol and polyethylene glycol on the duration of postoperative ileus following colorectal resection

In a prospective randomized study in 100 patients undergoing conventional (n=66) or laparoscopic (n=34) colorectal resection, mechanical lavage with 2 1 of a polyethylene glycol (PEG) solution (group A, n=50) combined with a laxative was compared with lavage with 4 1 of PEG alone (group B, n=50). The influence of bowel preparation on postoperative Hens was investigated. The efficacy of bowel preparation was determined intraoperatively by a surgeon blind to the type of preparation. The time interval between the end of the operation an first flatus or bowel movement was recorded. The efficacy of preparation was no different between the groups (group A: 94%, group B: 84%; P=0.5). The time lapse before first flatus (A: 3.1 ± 1.2 days, B: 3.2 ± 1.3 days; P = 0.6) or bowel movement (A: 3.9 ± 1.3 days, B: 4.1 ± 1.3 days; P = 0.5) also did not differ between the groups. The only factor found in multivariate analysis (age, sex, operation, duration and type of surgery, bowel preparation) to prolong the duration of postoperative ileus was the type of surgery. The first bowel movement occurred 3.2 ± 1.1 days after conventional surgery and 4.3±1.2 days (P<0.001) after laparoscopic surgery. The type of preoperative bowel preparation had no influence on the duration of postoperative Hens. The postoperative interval before the first bowel movement was shorter after laparoscopic surgery.

     

The Patient Factor

Long-term results of bariatric surgery are reviewed. The weight criteria for patient acceptance for bariatric surgery and their variation are presented graphically and discussed. Factors affecting patient selection in an attempt to improve outcome results in the small group of patients who currently achieve less weight loss than anticipated are defined. An attempt is made to define pre-operative criteria for selection of pure restrictive versus combined restrictive and malabsorptive procedures. Aspects of motivation, co-morbidity, age and pre-operative weight are discussed and the position statement of the ASBS in regard to laparoscopic bariatric surgery is defined.