Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial.

PURPOSE: Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures. METHODS: Children less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1year postoperatively. Telephone follow-up was performed at a minimum of 1.5years. RESULTS: 120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20min longer in the S group (P<0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4years (IQR 3-4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up. CONCLUSION: When minimal phrenoesophageal dissection is performed, EC sutures offer no advantages and increase operating time. LEVEL OF EVIDENCE: Level II.

When a Surgical Colleague Makes an Error.

Professionalism requires that doctors acknowledge their errors and figure out how to avoid making similar ones in the future. Over the last few decades, doctors have gotten better at acknowledging mistakes and apologizing to patients when a mistake happens. Such disclosure is especially complicated when one becomes aware of an error made by a colleague. We present a case in which consultant surgeons became aware that a colleague seemed to have made a serious error. Experts in surgery and bioethics comment on appropriate responses to this situation.

Minimal vs. maximal esophageal dissection and mobilization during laparoscopic fundoplication: long-term follow-up from a prospective, randomized trial.

PURPOSE: We have previously conducted a prospective randomized trial (PRT) comparing circumferential phrenoesophageal dissection and esophageal mobilization (MAX) to minimal dissection/mobilization (MIN). The MIN group had a decreased incidence of postoperative wrap herniation and need for reoperation. This study provides long-term follow-up of the patients from our center who participated in the PRT. METHODS: Parents of patients in the PRT were queried regarding symptoms, medication use, postoperative complications, and additional procedures. Medical records were reviewed. Student's t-test was used for continuous variables. Fisher's exact and chi-square with Yates correction were used where appropriate. RESULTS: Of patients from our center, 75.4% MAX and 72.5% MIN patients were contacted. Median time to follow-up was 6.5 years. A rise in the incidence of herniation was noted in both groups (22.7% to 36.5% MAX vs 2.8% to 12.2% MIN). Time to diagnosis of hernia was significantly longer in the MIN group (14.7±9.5 months MAX vs 30.2±23.6 months MIN, P=0.04). There was no significant difference between MIN and MAX group in reflux symptoms or medication use. CONCLUSION: Long-term follow-up demonstrates an increase in incidence of herniation in both groups. Previously demonstrated higher risk of wrap herniation with maximal esophageal dissection during laparoscopic fundoplication remains supporting original findings.

Laparoscopic excision of splenic cysts: a comparison to the open approach.

PURPOSE: The aim of this study was to evaluate the outcomes following excision of splenic cysts in children. METHODS: A retrospective chart review of all patients who underwent excision of a splenic cyst between 1990 and 2007 was performed. Age, cyst etiology, cyst size, preoperative imaging, and operative approach were evaluated. Outcome variables included length of postoperative hospitalization, cyst recurrence, postoperative imaging, the histologic lining of the cyst, and the need for additional procedures. RESULTS: During this 17-year period, 9 patients underwent excision of a splenic cyst. Four underwent an open operation and 5 had a laparoscopic procedure. In the open group, 2 patients underwent splenectomy, one patient had a partial splenectomy, and one cyst was aspirated and marsupialized. In the laparoscopic group, 4 patients underwent complete excision of the cyst and 1 underwent resection of the outer wall. The mean age was 12.3 years. Computed tomography was performed preoperatively in 8 patients and one child had an ultrasound study. The most common symptom was abdominal pain in 6 patients. Four patients had a history of recent abdominal trauma. The mean length of postoperative hospitalization was 2.75 days for the open group and 1.6 days for the laparoscopic cohort. One patient in the laparoscopic group had a recurrence. To date, no additional operations have been performed. CONCLUSIONS: Laparoscopic splenic cyst excision is comparable to open cyst excision and results in a decreased length of postoperative hospitalization.

Multimedia article. Laparoscopic fundoplication in an infant.

BACKGROUND: Laparoscopic fundoplication in infants and children is rapidly becoming the procedure of choice for surgical correction of symptomatic gastroesophageal reflux because of the advantages of reduced discomfort and decreased hospitalization. In addition, there may be a hidden benefit of an earlier return to work by the parents. METHODS: This video depicts the salient operative features for performing a laparoscopic fundoplication in an infant who presented with an acute life-threatening event, which was felt secondary to gastroesophageal reflux. In this operation, a 5 mm cannula was placed in the umbilicus through which insufflation was achieved and a 5 mm, 45 degrees angled telescope was inserted into the peritoneal cavity. The four instruments were placed directly through the abdominal wall using a stab incision technique rather than using cannulas. Moreover, the operation was performed using AESOP, the voice-activated telescopic holder, which provides a steady and consistent view. RESULTS: The operative technique was straightforward in that the short gastric vessels were divided, the crura were closed, and the esophagus was secured to the crura to keep the esophagus in an intraabdominal position and to prevent transmigration of the fundoplication wrap in the postoperative period. The length of the fundoplication should be around 2.0 cm and was measured to ensure that the fundoplication approximates this length. CONCLUSION: This patient made an eventful recovery and was discharged the following day. No complications have developed. [The full text of this article is a video computer file.]

Experience with laparoscopic adrenalectomy in pediatric patients.

BACKGROUND: Laparoscopic adrenalectomy (LA) is now being recognized as the standard in the management of benign adrenal pathology in adult patients. Few reports have described the use of this technique in pediatric patients. This study combines experience from 2 institutions with lateral transperitoneal LA in children to analyze our results and the clinical and biochemical response to laparoscopic adrenalectomy in patients with hormonally active adrenal tumors. METHODS: A bi-institutional retrospective review of all patients undergoing LA between January 1997 and January 2001 was performed. Clinical and biochemical data were obtained during routine follow-up. RESULTS: Seventeen laparoscopic adrenalectomies were performed during this period. The average operating time was 120 minutes, mean estimated blood loss was 25 mL, the mean size of the adrenal lesion was 4.8 cm, and the mean length of hospitalization was 35 hours. Resolution of clinical and biochemical parameters of adrenal hyperfunction was accomplished in all patients with adrenocortical hyperplasia and pheochromocytoma in postoperative follow-up. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safely and effectively with a short hospital stay, minimal blood loss, and excellent functional outcome in this age group. The authors believe laparoscopic adrenalectomy is an excellent approach for the management of benign pediatric adrenal pathology.

Minimally invasive bar repair for 'redo' correction of pectus excavatum.

BACKGROUND/PURPOSE: A small percentage of patients who have undergone traditional, "Ravitch-type" pectus excavatum repair present with unsatisfactory results and require a second procedure for correction. Reoperative open surgery for pectus excavatum has been associated with extensive dissection and substantial blood loss. The minimally invasive (MIS) bar repair for the correction of pectus excavatum has been gaining acceptance. This study evaluates the authors results with patients who have undergone the MIS bar repair for redo correction of their pectus excavatum. METHODS: A retrospective chart review of all patients undergoing MIS bar repair between December 1997 and August 2001 was performed. Information about demographics, deformity, operative course, complications, and early outcome was recorded. RESULTS: Ninety-two patients underwent MIS repair during this period. Ten patients had redo MIS bar repair for unsatisfactory prior open correction. Operating time was 52 minutes for standard patients and 70 minutes for the redo patients (P <.001). Blood loss and postoperative hospitalization were similar between groups. CONCLUSION: The minimally invasive pectus repair can be performed safely with minimal blood loss and short operating time in patients who have undergone prior unsatisfactory open repair of pectus excavatum and can be an alternative approach to reoperative open repair in these patients.

Lessons learned from a failed multi-institutional randomized controlled study.

BACKGROUND/PURPOSE: In 1996, the Surgical Sections of the Children's Cancer Group (CCG) and the Pediatric Oncology Group (POG) received National Cancer Institute funding to conduct a prospective, randomized, controlled, surgeon-directed study to evaluate the role of minimally invasive surgery (MIS) in children with cancer. Because of lack of patient accrual, the study was closed in 1998. The purpose of this study is to evaluate and describe those factors that impacted on study failure to ensure future successful clinical trials. METHODS: One hundred forty surgeons representing the surgical membership of CCG and POG as well as 111 institutions within CCG and POG were asked to complete a questionnaire about the failed clinical trial. The questionnaire focused on study objectives, organization, and institutional review board (IRB) submission. It also examined the surgeon's ability to perform the minimal access operation, the influence of the pediatric oncologist, and the existence of preconceived biases by surgeons, oncologists, and families. Statistical analysis was performed as appropriate. RESULTS: Eighty-six of 140 (62%) surgeons responded to the questionnaire. Only 23% of the potential protocols were submitted for IRB approval. Of responding surgeons, 39% were not actively performing MIS when the study opened. A surgeon's support of the study was directly related to when the surgeon received the protocols (P <.001) and whether the participating surgeon was actively participating in MIS (P <.016). The oncologist's knowledge and support of the study affected IRB submission and approval (P <.02) and was influenced by whether MIS was practiced at the institution (P <.05). The majority of responding surgeons believed the experimental question was relevant (P <.05). However, responding surgeons believed that a preconceived bias existed within both their local surgical and oncology communities favoring a particular surgical approach (P <.001), but this bias did not extend to the families (P >.05). CONCLUSION: The study failed because of lack of accrual for a variety of reasons: failure to submit to the institution's IRB, lack of surgical expertise with MIS procedures, and preconceived surgeon bias toward either an endoscopic or traditional open approach.

Management of intestinal atresia in patients with gastroschisis.

BACKGROUND/PURPOSE: Intestinal atresia occurs in approximately 10% to 20% of children with gastroschisis and may be missed at the initial closure if a thick peel obscures the bowel. Some investigators have identified intestinal atresia as a significant contributor to morbidity and mortality. The authors reviewed their experience with gastroschisis and intestinal atresia in an attempt to answer the following questions. What is the incidence of this association? How often is the intestinal atresia unrecognized as a result of the peel? What is the optimal management for infants with atresia and gastroschisis, and does the atresia affect morbidity or mortality? METHODS: The hospital charts and medical records of all patients with gastroschisis treated at our institution from 1969 to present were reviewed thoroughly. Parameters analyzed included gestational age (GA), birth weight (BW), antenatal diagnosis, mode of delivery, type of closure, era of repair, presence of other major anomalies, and development of necrotizing enterocolitis. Morbidity and mortality rates were examined. Characteristics of patients with and without atresia were compared. Chi-squared was used for crosstabular analysis. Sample parameters were compared with Student's t test. P values of less than.05 were considered significant. RESULTS: A total of 199 babies had gastroschisis and 25 (12.6%) had intestinal atresia. Intestinal atresia was initially unrecognized in 3 patients. Most patients (80%) underwent primary closure of the abdominal wall. Initial stoma formation and delayed anastomosis was performed in 12 (48%) patients, none of whom required prosthetic material for abdominal wall closure. Initial stomas were avoided in 5 patients who required SILASTIC (Dow Corning, Midland, MI) silos. Skin closure alone was used in 2 babies. The level of the atresia was most commonly jejunoileal (20 of 25, 80%). Mean hospital stay was increased in babies with intestinal atresia, 36.2 versus 63.1 days (P <.001). CONCLUSIONS: Although patients with intestinal atresia did have feeding delays, an increased incidence of adhesive intestinal obstruction, and prolonged hospitalization, neither chi(2) nor logistic regression analysis showed any correlation with mortality. Intestinal repair at the first operation is sometimes possible and depends on the severity of the peel. Delayed repair of the atresia after a period of bowel decompression and parenteral nutrition is preferred, but in certain situations (colonic atresia, necrotic intestine, complicated atresia) may not be possible. The combination of stomas and prosthetic material can be avoided in almost all patients. A management algorithm for patients with atresia and gastroschisis is discussed.

Minimally invasive repair of pectus excavatum: a single institution's experience.

BACKGROUND: The Nuss repair of pectus excavatum is a relatively new, minimally invasive surgical (MIS) alternative to the traditional open "Ravitch-type" operation. We have one of the larger single-center experiences to date, and we conducted this clinical study to evaluate our early experience, emphasizing initial outcome and technical modifications designed to minimize complications. METHODS: A retrospective chart review was performed on 112 patients who underwent 116 pectus excavatum repairs between January 1995 and January 2001. The Nuss procedure was performed in 80 patients, and open repair was performed in 32 patients. Information about demographics, deformity, operative course, complications, and early outcome was recorded. RESULTS: Operative duration was 143 minutes for the open group and 53 minutes for the Nuss MIS group (P <.001). Blood loss was 6 mL/kg for the open group and 0.5 mL/kg for the MIS group (P <.001). Postoperative hospitalization was 3.2 days for the open group versus 3.7 days for the MIS group (P<.05). CONCLUSIONS: The MIS pectus repair can be performed safely with minimal blood loss and reduced operative time. Short-term analysis of the quality of repair, including absence of preoperative symptoms, patient satisfaction, and cosmetic appearance are encouraging.

Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children.

BACKGROUND/PURPOSE: In the past, surgical treatment in achalasia usually has been reserved for patients whose dysphagia does not respond to pneumatic dilatation. The success of minimally invasive myotomy, however, has resulted in a shift in practice in adult patients, whereby laparoscopic surgery is becoming preferred as primary treatment by most gastroenterologists and surgeons. The aim of this study was to assess the efficacy of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. METHODS: Thirteen patients with esophageal achalasia (median age, 15 years; 6 boys and 7 girls; median duration of symptoms, 24 months) underwent laparoscopic Heller myotomy and Dor fundoplication between 1996 and 1999. Two patients had been treated previously by pneumatic dilatation, and 1 patient had received intrasphincteric Botulinum toxin injections. RESULTS: Median duration of the operation was 130 minutes. The patients were fed after an average of 33 hours, and they all left the hospital within 2 days. At a median follow-up of 19 months, there was no residual dysphagia in any patient. CONCLUSIONS: Laparoscopic Heller myotomy and Dor fundoplication were effective and safe for children with esophageal achalasia. Hospital stay and recovery time was short, and the functional results were excellent. These data support the notion that laparoscopic Heller myotomy should become the primary treatment of esophageal achalasia in children.

Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience.

BACKGROUND: Vascular rings are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this report, we offer a description of our approach and a review of our 25-year experience. METHODS: A retrospective review was conducted of all pediatric patients with symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1974 to 2000. RESULTS: Thirty-one patients (38%) of eighty-two patients (mean age, 1.7 years), were identified with double aortic arch, 22 patients (27%) with right arch left ligamentum, and 20 patients (24%) with innominate artery compression. Our diagnostic approach emphasized barium esophagram, along with echocardiography. This regimen was found to be reliable for all cases except those with innominate artery compression for which bronchoscopy was preferred, and except those with pulmonary artery sling for which computed tomography or magnetic resonance imaging, in addition to bronchoscopy, were preferred. Left thoracotomy was the most common operative approach (70 of 82; 85%). Ten patients (12%) had associated heart anomalies, and 6 (7%) patients underwent repair. Complications occurred in 9 (11%) patients and led to death in 3 (4%) patients. CONCLUSIONS: In our practice, barium swallow and echocardiography are sufficient in diagnosing and planning the operative strategy in the majority of cases, with notable exceptions. Definitive intraoperative delineation of arch anatomy minimizes the risk of misdiagnosis or inadequate treatment.

Incidence and significance of pneumomediastinum after laparoscopic esophageal surgery.

BACKGROUND: Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. METHODS: Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean +/- SEM. RESULTS: Twenty-five men (56%)and 20 women (44%) aged 33.0 +/- 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. CONCLUSION: Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients.

Differentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. A report from the Surgical Discipline Committee of the Children's Cancer Group.

BACKGROUND/PURPOSE: Young patients with differentiated thyroid cancer typically present with regional lymph node involvement (60% to 80%), and 10% to 20% have distant metastases. This study characterizes the clinical presentation, treatment, and outcome in patients with differentiated thyroid cancer who were less than 21 years of age at diagnosis and who presented with distant parenchymal metastases. METHODS: A retrospective, multi-institutional data base that included 327 patients in this age group with differentiated thyroid carcinoma was searched for patients who presented with distant metastases, and 83 cases (25%) were found. The median time to first disease progression was 2.4 years (range, 0.1 to 12.4 years) and the overall median follow-up was 10.9 years (range, 1.0 to 42.1 years). RESULTS: The median age at diagnosis was 14.6 years (range, 6.6 to 20.8 years); 69% were girls and 92% were white. In 12%, there was a history of prior head and neck irradiation, and 10% of these patients had a family history of carcinoma. Preoperative needle biopsies were performed in 25%. Regional lymph nodes were positive in 90%, and extrathyroidal extension occurred in 48%. The site of distant metastases included the lungs in all patients. Total thyroidectomy, subtotal thyroidectomy, lobectomy, and nodule excision was done in 66%, 24%, 3%, and 8% of patients, respectively. There was no residual cervical disease after surgery in 75%, whereas 14% had microscopic and 11% had gross residual. Histopathologic subtypes included papillary-follicular (48%), papillary (42%), and follicular (10%). The median tumor size was 3.0 cm (range, 0.4 to 11.0 cm). In this group, 100% of patients received adjuvant iodine 131I therapy, and the overall survival rate at 10 years was 100%. The progression-free survival rate was 76% at 5 years and 66% at 10 years from diagnosis. CONCLUSIONS: A significant number of young patients with thyroid cancer present with distant metastases and will require radioiodine therapy. This should be considered when planning the surgical approach because total or subtotal thyroidectomy facilitates 131I imaging and treatment. Although about one third of these patients will experience relapse or disease progression, the overall mortality rate is low.

Twenty-five-year surgical experience with pheochromocytoma in children.

Our objective was to analyze the presentation, diagnostic localization, operative management, histology, and long-term outcome of a single center's experience with pheochromocytomas in children. A chart review was done to identify all operatively managed pheochromocytomas in patients age 18 years or younger. Open and laparoscopic cases were included. We reviewed the presentation, diagnostic imaging, localization, operative management, pathology, and postoperative outcome of these patients. Clinic visits, contact with the tumor registry, and telephone interviews were used for follow-up. From 1973 through 1999, there were 11 children (four males and seven females) with 14 pheochromocytomas. Two (18.2%) patients had bilateral adrenal lesions and one patient had both adrenal and extra-adrenal tumors. Six (54.5%) patients had extra-adrenal lesions. The average age at operation was 14.7 years (range 9-18 years). Nine (82%) patients had significant hypertension at presentation. CT was used to localize the tumor in eight patients and urine catecholamine levels were used to confirm the diagnosis. Two of the cases were associated with inherited syndromes (multiple endocrine neoplasia 2A and von Hippel-Lindau). Ten patients underwent an open operation and one patient had a laparoscopic resection. The average patient follow-up was 9.2 years (range 9 months to 25 years). There were no operative complications and all patients were alive and well at the time of last follow-up. Three patients (27.2%) had tumors with microscopic malignant features. No tumors recurred or had evidence for metastatic spread. We conclude that peak incidence of pheochromocytomas in children is in early adolescence. Resection can be carried out safely with minimal morbidity and mortality. Current best management of this entity includes establishment of a biochemical diagnosis, adequate preoperative blockade, appropriate imaging, and an individualized operative approach based on tumor location and size.

Laparoscopic left adrenalectomy for pheochromocytoma in a child.

Although uncommon, adrenalectomy occasionally is indicated in children. To date, this procedure has required either a laparotomy or a flank incision. The authors report the case of a child with episodic palpitations, diaphoresis, chest discomfort, and occipital headache who underwent laparoscopic adrenalectomy for pheochromocytoma without complication.

Laparoscopic cholecystectomy in children: lessons learned from the first 100 patients.

BACKGROUND/PURPOSE: Laparoscopic cholecystectomy is a very common operation in adults but is relatively infrequently required in children. A retrospective review of 100 consecutive infants and children undergoing laparoscopic cholecystectomies from 1990 to 1998 was performed to see what lessons have been learned from this relatively large population of pediatric patients. RESULTS: The patients ranged in age from 25 to 230 months, with a mean of 105 months. Only 19 patients had hemolytic disease as the etiology for their cholelithiasis. Two patients had biliary dyskinesia. Seventy-eight patients underwent an elective operation. Twenty-two children required urgent hospitalization because of complications from their cholelithiasis: acute cholecystitis (n = 7), jaundice and pain (n = 6), gallstone pancreatitis (n = 5), acute biliary colic (n = 4). All 6 patients who presented with jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) before their laparoscopic cholecystectomy. Two patients required laparoscopic choledochal exploration. The operating time and postoperative hospitalization were significantly longer (P = .0005) in the complicated group when compared with the elective patients. No significant complications such as the need for reoperation, injury to the choledocuhus or to other viscera, bile leak, or retained choledocholithiasis occurred. CONCLUSIONS: Laparoscopic cholecystectomy is a safe, effective procedure in children for removal of the gallbladder. The exact role of routine cholangiography and ERCP remains unclear.