Laparoscopic versus open Kasai procedure for biliary atresia: long-term results of a randomized clinical trial.

PURPOSE: The role of the laparoscopic approach for the Kasai procedure in the management of biliary atresia is still controversial. The aim of this study is to compare the long-term results of the laparoscopic Kasai procedure (LKP) to the open Kasai procedure (OKP). METHODS: A randomized clinical trial was carried out from October 2009 to March 2017. Patients diagnosed with biliary atresia type III were randomized into 2 groups: one group underwent LKP and the other group-OKP. All the surgical procedures were performed by the same surgeon with the same technical principles. The long-term outcomes were compared between the two groups. RESULTS: 61 patients underwent LKP and 61 patients-OKP, with a median age at the surgery of 79.7 days. The two groups had no significant differences regarding the patients' baseline characteristics. At follow-up up to 142 months, the jaundice-free rate at the 6th postoperative month for LKP and OKP was 52.5% and 60.7%, respectively (p = 0.23). The 10-year cumulative survival after LKP tended to be inferior to OKP, respectively 44.3% vs. 58.9% (p = 0.09). CONCLUSIONS: In this study, the long-term results of LKP tended to be inferior compared to OKP although the differences were not significant.

Prevalence and predictors of cytomegalovirus retinitis in HIV-infected patients with low CD4 lymphocyte counts in Vietnam.

We describe the results of a study to determine the prevalence and characteristics of cytomegalovirus (CMV) retinitis among HIV-infected patients in Vietnam. We conducted a cross-sectional prospective study of patients with CD4 lymphocyte count ≤100 cells/mm(3)recruited from public HIV clinics. The diagnosis was made by a trained ophthalmologist using slit lamp biomicroscopy and corroborated on fundus photography. A total of 201 patients were screened. The median age was 32 years, 77% were men, median CD4 count was 47 cells/mm(3), and 62% were on antiretroviral treatment. Prevalence of CMV retinitis was 7% (14/201, 95% CI 4-11%). CMV retinitis was not associated with age, gender, injection drug use, CD4 count, WHO clinical stage, or antiretroviral treatment status. Blurring of vision and reduced visual acuity <20/40 were associated with CMV retinitis, but only 29% of patients with the diagnosis reported blurry vision and only 64% had abnormal vision. On multivariate analysis, the sole predictor for CMV retinitis was decreased visual acuity (OR 22.8,p < 0.001). In Ho Chi Minh City, CMV retinitis was found in 7% of HIV-infected patients with low CD4. HIV-infected patients with a CD4 count <100/mm(3)or who develop blurring of vision in Vietnam should be screened for CMV retinitis.

Is the laparoscopic operation as safe as open operation for choledochal cyst in children?

AIM: The aim of this study was to compare the safety of laparoscopic operation with open surgery for choledochal cyst in children. METHODS: Early outcomes of open surgery from January 2001 to December 2006 were compared with early outcomes of laparoscopic operations from January 2007 to July 2010. The main outcome variables included intra- and early postoperative complications, operative time, rate of reintervention, and duration of postoperative stay. RESULTS: There were 307 patients in the open operation group and 309 patients in the laparoscopic operation group. There was no significant difference in cyst diameter between the 2 groups. The operative time was longer in the laparoscopic operation group. The number of patients requiring blood transfusion was lower in the laparoscopic operation group. Intraoperative complications were low in both groups and not significantly different. The rate of postoperative complications was lower in the laparoscopic operation group but not significantly. The rate of reintervention was significantly lower in the laparoscopic operation group. The postoperative stay was significantly shorter in the laparoscopic operation group. CONCLUSION: Laparoscopic operation is as safe as open operation for choledochal cyst. The postoperative stay was significantly shorter in the laparoscopic operation group.

Laparoscopic near-total pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy: report of two cases.

Near-total pancreatectomy for persistent hyperinsulinemic hypoglycemia (PHH) of infancy has been done, so far, only by open surgery, and the application of laparoscopic techniques for this procedure has not been documented. In this article, we report 2 cases of successful laparoscopic near-total pancreatectomy for PHH. Two infants underwent surgery at the age of 60 and 54 days and at body weights of 7700 and 5700 g, respectively. Four ports were used for the patient 1 and three ports plus fixation sutures of the stomach to the abdominal wall for stomach traction were used for patient 2. The pancreas was dissected free from the spleen and splenic vessels and was mobilized beyond the right side of the superior mesenteric vein. The head of the pancreas was transected by using the Harmonic Scalpel (Tokyo, Japan), leaving only 1 cm of the pancreas along the duodenal C-loop. The operative times were 180 and 160 minutes. There was neither an intra- nor a postoperative abdominal complication. Oral feeding was resumed on the postoperative day 1. The blood glucose level increased immediately after the operation. Follow-up period of 12 months showed normal levels of blood sugar and insulin for both patients. Laparoscopic near-total pancreatectomy can be a safe, effective procedure for small infants with PHH.

Thoracoscopic repair in the neonatal intensive care unit for congenital diaphragmatic hernia during high-frequency oscillatory ventilation.

AIM: The aim of this work was to report the technique and result of thoracoscopic repair for a newborn with congenital diaphragmatic hernia (CDH) under high-frequency oscillatory ventilation (HFOV) in the neonatal intensive care unit (NICU). METHODS: Ventilation was supported by HFOV. The patient was placed in the right lateral decubitus position. Thoracoscopic surgery was performed through three 5-mm trocars. Carbon dioxide insufflation was maintained in the thoracic cavity at a pressure of 6-8 mm Hg. The hernia defect was repaired by using interrupted sutures with extracorporeal knots. RESULTS: The operation lasted 60 minutes. The intraoperative course was uneventful. Normal vital signs and PO(2) value were maintained throughout the operation. The patient had a normal chest X-ray 1 month after discharge. CONCLUSION: Thoracoscopic repair of CDH in the NICU during HFOV is feasible and safe.

One-stage operation for Hirschsprung's disease: experience with 192 cases.

OBJECTIVE: To report early and late outcomes after a one-stage operation for Hirschsprung's Disease (HD). METHODS: Between December 2001 and December 2004, 192 patients (165 boys and 27 girls) underwent a one-stage operation for HD. Operative techniques included modified Pfannenstiel incision (48 cases), modified posterior sagittal approach (64 cases), and primary laparoscopic-assisted endorectal colonic pull-through procedure (80 cases). Ages ranged from 15 days to 36 months. The diagnosis was confirmed by operative frozen biopsies. RESULTS: An aganglionic segment was located in the rectum in 105 patients, in the sigmoid colon in 83 and in the left colon in four. There were no operative deaths. In one patient, a small intestinal perforation occurred 3 days after operation and required ileostomy. Anastomotic leakage occurred in four patients treated by modified posterior sagittal approach. The median hospital stay was 6 days, excluding five patients who required enterostomy. One hundred and forty-five patients were followed-up for 6-40 months after discharge from the hospital. All patients had spontaneous defaecation. The stool frequency ranged from one to four times daily in 113 patients, five to six times in 13, and over six times in four patients. There were seven patients with faecal incontinence and eight with constipation. CONCLUSION: One-stage operation is a safe procedure for HD.

Thoracoscopic repair for right congenital diaphragmatic hernia.

PURPOSE: The aim of this study is to describe the surgical technique and initial results of thoracoscopic repair for the right congenital diaphragmatic hernia (CDH). METHODS: Patients underwent surgery under conventional general anesthesia. The operation was carried out by using one optical and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-4 mm Hg. The hernia defect was repaired by using nonabsorbable interrupted sutures with extracorporeal knots. RESULTS: There were 16 patients, including 13 boys and 3 girls. Six patients were newborns and the other 10 patients were infants or elders. The mean operative time was 82 minutes. Conversion was required in 1 patient. There were no operative or postoperative complications. However, there was one postoperative death. There was one recurrence on postoperative day 39. Follow-up ranged from 2 to 77 months. A normal chest X-ray was shown in all patients. CONCLUSION: Thoracoscopic repair is feasible and safe for children with a right CDH, including selected newborns.

Primary laparoscopic endorectal colon pull-through for Hirschsprung's disease: early results of 61 cases.

OBJECTIVE: To report early results after a one-stage laparoscopic endorectal colon pull-through for Hirschsprung's disease (HD). METHODS: Between January 2002 and June 2004, 61 patients underwent primary laparoscopic-assisted endorectal colon pull-through procedure for HD. Ages ranged from 21 days to 36 months. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was performed according to Georgeson's technique. We left a short rectal seromuscular sleeve 2 cm from the dentate line. RESULTS: The aganglionic segment was located in the rectum in 33 patients, in the sigmoid colon in 27 patients and in the left colon in one patient. The median operating time was 140 minutes. There were no operative complications or deaths. No conversion was required. There was minimal blood loss during surgery. Clear fluids were given 12 hours after surgery and milk was given on the 2nd day. In one patient, small intestinal perforation occurred 3 days after surgery and required ileostomy. The median hospital stay was 6 days, excluding one patient with intestinal perforation. Spontaneous defaecation occurred in all patients before discharge. CONCLUSION: One-stage laparoscopic-assisted colon pull-through is a safe and effective procedure for HD.

Tubularized longitudinal island flap of the mucosa and skin on the dorsum of the penis in the treatment of hypospadias: experience from 176 cases.

OBJECTIVE: To report the result of the treatment of hypospadias using tubularized longitudinal island flap of the mucosa and skin on the dorsum of the penis. METHODS: Between January 1995 and December 2003, 176 patients were operated on using this technique. Among them, 124 patients had penile hypospadias, 35 had the penoscrotal form, four had the scrotal form and three patients had the perineal form. After removing the whole chordee, a longitudinal pedicle island flap of mucosa and skin was created. The flap was transposed to the ventral side of the penis by the buttonhole manoeuvre, and anastomosed to the meatus. The flap was tubularized creating a neourethra. RESULTS: The length of urethral defect varied from 1.5 to 10 cm (mean, 3.5 cm). The single longitudinal flap was used in 171 patients. The combination of a longitudinal flap and a local flap was used in five patients. Fistulae occurred in 13 patients (7.4%). Torsion of the penile axis did not occur in any patient. All children voided with a single straight urinary stream, and had a normal appearance of the meatus. CONCLUSION: The technique has a low fistula occurrence rate and a good cosmetic result.