Laparoscopic cecostomy button placement for the management of fecal incontinence in children with Hirschsprung's disease and anorectal anomalies.

BACKGROUND: Antegrade colonic enemas offer a surgical solution for many children with chronic constipation and encopresis associated with Hirschsprung's disease and anorectal malformations. This study demonstrated the feasibility of a new laparoscopic technique for cecostomy button placement (LCBP) to allow antegrade enema treatment. METHODS: Charts of children with encopresis who underwent LCBP between 1999 and 2001 were reviewed. The age, weight, primary diagnosis, operative time, hospital stay, associated complications, follow-up duration, and outcome of the patients were recorded. The surgical technique used a "U-stitch" method and a chait tube or a standard gastrostomy button. A follow-up telephone survey was conducted to assess parental satisfaction and overall success in continence. RESULTS: Seven patients ages 4 to 12 years (mean, 7.3 +/- 1.3 years) and weighing 15 to 44 kg (mean, 24.5 +/- 4 kg) underwent LCBP over a 2-year period. The mean follow-up period was 15 +/- 4 months (range, 6-33 months). Four patients had anorectal malformations, and three patients had Hirschsprung's disease. For all the patients, LCBP was accomplished without any intraoperative complications. The mean operative time was 33 +/- 2 min, and the hospital stay was 2 to 5 days (mean, 3.8 +/- 0.5 days). The patients received one or two daily antegrade enemas, and none had accidental bowel movements. Episodes of soiling at night once or twice a week were observed with two children. Two patients had hypertrophic granulation tissue formation, which responded to topical therapy. The button was uneventfully changed twice in one patient because of mechanical malfunction. CONCLUSION: To manage overflow incontinence of children with anorectal malformations and Hirschsprung's disease, LCBP is a technically straightforward, effective, and reversible method for the placement of a cecostomy button.

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy.

BACKGROUND: The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis. METHODS: Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction. RESULTS: The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 +/- 3 min; open group, 57 +/- 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 +/- 7 h for the laparoscopic group and 127 +/- 12 h for the open group (p = 0.08). The hospitalization time was 189 +/- 14 h for the laparoscopic group, as compared with 210 +/- 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction. CONCLUSIONS: Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.

Changing patterns in the diagnosis of hypertrophic pyloric stenosis.

The records of 216 infants who had surgical correction of hypertrophic pyloric stenosis between 1980 and 1984 at the Children's Hospital of Alabama were reviewed. A significant increase in the reliance on upper gastrointestinal roentgenographic series and abdominal sonography for confirmation of the diagnosis of hypertrophic pyloric stenosis was noted in our patients when compared to previous reports. Despite the preoperative presence of a palpable pyloric mass in 192 (89%) of the patients, 174 (81%) had a diagnostic imaging procedure. Similar high rates of imaging studies were noted when the records of patients with hypertrophic pyloric stenosis from 1980 and 1984 were reviewed at three other institutions. Palpation of a hypertrophied pylorus is diagnostic of hypertrophic pyloric stenosis. Careful physical examination makes diagnostic imaging unnecessary in the majority of infants with symptoms suggesting hypertrophic pyloric stenosis. Diagnostic imaging for suspected hypertrophic pyloric stenosis should be used only for those infants with persistent vomiting in whom careful and repeated physical examinations fail to detect a palpable pyloric mass.

Congenital diaphragmatic hernia survival and use of extracorporeal life support at selected level III nurseries with multimodality support.

BACKGROUND: Congenital diaphragmatic hernia (CDH) has been cited to have a mortality rate of 50%. There have been multiple studies at individual institutions demonstrating potential benefits from various strategies including extracorporeal life support (ECLS), delayed repair, and lower levels of ventilator support. There has been no multicenter survey of institutions offering these modalities to describe the current use of ECLS and survival of these infants. In addition, the relationship between the number of patients with CDH managed at an individual institution and outcome has not been evaluated. METHODS: We queried 16 level III neonatal intensive care centers on the use of ECLS and survival of infants with CDH who were treated during 2 consecutive years (1993 to 1995). Data are presented as mean +/- SEM, median, and range. RESULTS: Data were collected on 411 patients. Of these, 71% +/- 8% were outborn and 8% +/- 3% were considered nonviable. Overall survival of CDH infants was 69% +/- 4% (range, 39% to 95%). The survival rate of infants on ECLS was 55% +/- 4%, whereas survival of infants not requiring ECLS was significantly increased at 81% +/- 5% (p = 0.005). The mean rate of ECLS use was 46% +/- 2%. There was no correlation between the number of cases per year at an individual institution and overall survival, ECLS survival, or ECLS use (r = 0.341, 0.305, and 0.287, respectively). There was also no correlation between case volume at an individual institution and ECLS survival (r = 0.271). CONCLUSIONS: The current survival rate and rate of ECLS use in infants with CDH at level III neonatal intensive care units in the United States are 69% +/- 4% and 46% +/- 2%, respectively. There is no correlation between the yearly individual center experience with managing CDH and rate of ECLS use or outcome.

Primary closure of gastroschisis. Facilitation with postoperative muscle paralysis.

Although most surgeons prefer primary closure of gastroschisis, staged closure is most commonly needed because of marked visceroabdominal disproportion. We have modified the usual primary fascial closure by introducing postoperative muscle paralysis through the use of a nondepolarizing neuromuscular blocking agent. The result was a higher percentage of patients amenable to primary closure. Twenty-nine patients with gastroschisis were treated by us during a 5 1/2-year period. Primary fascial closure was possible in 20 cases (69%). In 17 of the 20 patients, postoperative paralysis was induced for two to three days to avoid the complications associated with increased intraabdominal pressure. Postoperative complications were few.

Gastric volvulus in the newborn.

A review of the world literature has revealed only 11 cases of gastric volvulus symptomatic in the first month of life. To those 11, this report adds two cases of intrathoracic organoaxial gastric volvulus that were observed in the first week of life and were managed operatively. Gastric volvulus should be considered in the differential diagnosis of newborn infants initially observed to have persisting regurgitation, vomiting, and respiratory distress. The diagnosis can be made with plain thoracoabdominal roentgenograms and confirmed by upper gastrointestinal contrast studies. Prompt surgical management is indicated and should include reduction and fixation of the stomach and repair of associated anomalies. The results of early surgery are excellent.

Urokinase therapy for Silastic catheter-induced intravascular thrombi in infants and children.

Among the serious complications encountered with long-term, indwelling Silastic central venous catheters are catheter-induced intravascular thrombi. These thrombi are usually treated by removal of the catheter to prevent thrombus propagation, embolization, or infection. We treated ten patients with urokinase infusion who had experienced 12 incidents of induced intravascular thrombi. Catheter phlebography and two-dimensional echocardiography were used for diagnosis and follow-up. Eleven of the 12 episodes were treated successfully, with complete dissolution of the thrombus. One patient with a calcific thrombus had only partial clot lysis and required catheter removal. By utilizing urokinase infusion to treat Silastic catheter-induced intravascular thrombi, nine of ten central venous catheters were preserved and the possible need for thrombectomy was averted. No serious complications were encountered. In our experience, urokinase therapy has been an effective and safe method for treating Silastic catheter-induced intravascular thrombi.

Advances in minimally invasive surgery in children.

Minimal access pediatric surgery has developed more slowly than its adult counterpart for several reasons. Surgical pain and perioperative stress associated with open procedures have been underappreciated in children. Appropriately sized instrumentation was slow to develop because the focus of the marketplace was the adult. The advanced techniques required for pediatric laparoscopic procedures are associated with a relatively long learning curve. Reports documenting the safety, efficacy, and cost effectiveness of pediatric endosurgery are fueling a rapid evolution in instrumentation and minimal access procedures for children. This evolution will eventually influence most pediatric surgical procedures, changing the paradigm of the practice of pediatric surgery. It is the pediatric patient who has the most to gain from these alterations in their surgical care with less pain, decreased hospital days, and earlier return to regular activities.

Weight gain and triceps skinfolds fat mass after gastrostomy placement in children with developmental disabilities.

OBJECTIVE: To determine appropriate outcome indicators of nutritional status that are measurable over time after gastrostomy placement in children with severe neurologic impairments. DESIGN: Twenty-two nonambulatory children met the selection criteria: feeding by gastrostomy of at least 50% of total energy, age between 1 and 12 years, diagnosis of neurologic impairments, and presurgical recommendation for weight gain. Each child served as his or her own control; three assessments were made after gastrostomy placement. SETTING: Children were seen in specialty outpatient clinics. STATISTICAL ANALYSES: Scores and Pearson product moment correlations. RESULTS: Outcomes of gastrostomy placement were (a) increase in actual weight, (b) increase in weight-age equivalent, (c) rate of weight accretion as expected by National Center for Health Statistics growth charts and improved z scores for half of the children, and (d) improvement in triceps skinfolds percentiles for nearly half (n = 10) of the children. The results reflect the heterogeneity of children with severe disabilities. Pearson correlations showed a significant relationship between chronologic age and weight-age equivalent (r = .96), but not for weight for age and weight-age equivalent, or triceps skinfolds fat mass and weight-age equivalent. CONCLUSIONS/APPLICATIONS: Weight and triceps skinfolds fat mass were appropriate outcome indicators of nutritional status measurable over time. Weight-age equivalent and z scores were more helpful than standard growth plots for interpreting weight gain over time. Our data also support findings that undernutrition limits growth before gastrostomy placement in patients with disabilities. Nutritionists are encouraged to track improvement in nutritional status after gastrostomy placement with measurements of triceps skinfolds fat mass and to use the information to support families facing decisions about the need for this surgery.

Weight and length increases in children after gastrostomy placement.

OBJECTIVE: To document catch-up growth in children in the first 18 months after gastrostomy surgery and characterize how weight and length growth differ according to medical and nutritional risks. DESIGN: Repeated measures study to evaluate weight and linear growth in gastrostomy-fed children. SUBJECTS/SETTING: Seventy-five subject met the selection criteria; gastrostomy placement anytime from birth to age 6.5 years, diagnosis of failure to thrive before gastrostomy. surgery, absence of nonmedical barriers to adequate nutrition. Children were seen in specialty outpatient clinics. OUTCOME MEASURES: Three measurements of weight and length: at the time of surgery and 12 and 18 months after surgery. STATISTICAL ANALYSES: Paired t tests of z scores were used to determine catch-up growth. Analysis of variance used variables (age of placement, ambulatory status, prematurity, mode of feeding) to determine statistically significant predictors of growth. RESULTS: After gastrostomy surgery, catch-up growth was observed in height and weight for children regardless of prematurity or age at the time of gastrostomy placement. Ambulatory children did not achieve catch-up growth, but nonambulatory children did. At 18 months after surgery, catch-up growth occurred in children whose sole source of nutrition was through occurred in children whose sole source of nutrition was through the gastrostomy, as well as in those who were able to receive nutrition by mouth. Children with a diagnosis of cerebral palsy experienced better growth than children with other diagnoses. CONCLUSION/APPLICATION: Failure to thrive in children up to age 6.6 years can be corrected when adequate nutrition is provided. Benefits of gastrostomy surgery observed in catch-up growth reinforce the importance of medical nutrition therapy.

Surgical and laparoscopic techniques for feeding tube placement.

Surgeons have at their disposal multiple options for providing enteral access in a myriad of circumstances. This article reviews the techniques for surgical placement of enteral access as well as the indications, benefits, and complications for each procedure. The feeding tubes commonly available are described, and considerations involved in the choice of procedure are discussed.

Management of cholestasis in infants with very low birth weight.

Infants with very low birth weight (VLBW) are at increased risk of cholestasis when compared with older infants and children. Factors associated with this increased risk of cholestasis include immaturity of the biliary excretory system, a diminished immune response to sepsis, an increased incidence of necrotizing enterocolitis and short bowel syndrome, as well as an increased exposure to parenteral nutrition (PN). The current literature on cholestasis in VLBW infants and the factors that mediate the initiation and progression of cholestatic liver damage is reviewed. A protocol for managing infants with cholestatic jaundice is presented, and a case report is included that shows use of the protocol to normalize the bilirubin in a VLBW infant with severe cholestatic jaundice.

Fundoplication and gastrostomy.

Fundoplication and gastrostomy are among the most frequently performed procedures in infants and children. A laparoscopic approach with decreased morbidity has made fundoplication (with or without gastrostomy) more acceptable for patients who have significant gastroesophageal reflux disorders. Diagnostic evaluations to determine the presence of pathological gastroesophageal reflux have remained the same for patients being considered for open or laparoscopic procedures. Gastrostomy alone also is performed for patients who have swallowing difficulties or failure to thrive, after excluding the presence of gastroesophageal reflux. The authors review the indications and techniques of laparoscopic fundoplication and gastrostomy, as well as their experience with 390 patients.

Surgical options for short bowel syndrome.

Most children with short bowel syndrome experience spontaneous small bowel adaptation over time. This allows the majority to be weaned from parenteral nutrition. There are, however, some children who cannot be weaned and are potential candidates for techniques to promote intestinal adaptation and intestinal lengthening. Here, surgical therapeutic options are described, literature reviewed, and reported results evaluated. Surgical procedures for children with short bowel syndrome have high complication and failure rates, but in most cases are a less invasive option than intestinal transplantation.

Laparoscopic pull-through procedure for Hirschsprung's disease.

Contemporary surgical management of Hirschsprung's disease (HD) has evolved toward resection and reconstruction earlier in life. The introduction and miniaturization of laparoscopic instrumentation currently permits the application of this approach to the treatment of HD in the neonate. The authors' experience with this technique demonstrates several potential advantages over the "classical" two-stage operation.

Short bowel syndrome.

Improvements in parenteral nutrition and supportive therapy have led to a growing population of patients who survive for prolonged periods with short bowel syndrome. Definitive treatment for these patients requires innovative therapy based on a sound knowledge of small intestinal physiology and adaptation. Current understanding of short bowel pathophysiology and of intestinal adaptation are reviewed. Medical and surgical therapeutic options are described, highlighting the promotion of small bowel adaptation and methods to increase the small intestinal mucosal mass.

Pediatric laparoscopic appendectomy for acute appendicitis.

BACKGROUND: The benefit of laparoscopy in the treatment of pediatric acute appendicitis continues to be controversial, particularly as it relates to operative time and costs. METHODS: We reviewed the charts of 200 children who underwent appendectomy for acute appendicitis concurrently over 35 months at a large teaching children's hospital. RESULTS: Laparoscopic ( n = 105) [corrected] and open ( n = 95) appendectomies were performed. The operative times and postoperative lengths of hospital stay were similar for the two groups. The mean total hospital cost for the laparoscopic group (5,572 dollars) was significantly higher than for the open group (4,472 dollars); ( p < 0.01). CONCLUSIONS: Notably, the results show similar operative times for laparoscopic and open appendectomy. The cost of laparoscopic appendectomy for acute appendicitis is higher than for the open procedure. This study challenges health care providers to reduce costs and develop new ways to measure beneficial outcomes in a pediatric population that may reveal laparoscopic benefits.

Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery.

BACKGROUND: Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences. METHODS: A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999. RESULTS: In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization ( p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE ( p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min ( p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE ( p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases. CONCLUSIONS: These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.

Outcome and intestinal adaptation in neonatal short-bowel syndrome.

We reviewed 52 consecutive patients with short-bowel syndrome (SBS) treated with long-term parenteral nutrition (PN) from 1978 through 1990. The SBS etiologies included necrotizing enterocolitis (NEC) in 26 patients (50%), abdominal wall defects in 11 (22%), jejunoileal atresia in 6 (12%), midgut volvulus in 4 (8%), Hirschsprung's disease in 3 (6%), and segmental volvulus and cloacal exstrophy in 1 (2%) each. The average initial small bowel length was 48.1 cm, and only 31% of the patients retained an ileocecal valve (ICV). The mean duration of PN therapy was 16.6 months, and 39 patients (75%) were successfully weaned from it. Forty-three patients (83%) survived. Significant differences between the initial 20 patients treated from 1978 through 1984 and the next 32 from 1985 through 1990 were duration of PN therapy (25.1 v 11.4 months; P = .04), incidence of PN-associated jaundice (80% v 31%; P = .001), and survival (65% v 94%; P = .02). NEC patients had a significantly lower mean birthweight than those with other etiologies (mean, 1,367 v 2,544 g; P less than .0001) but did not differ in initial small bowel length, ICV retention rate, duration of PN treatment, incidence of successful PN weaning, or outcome. The presence of an ICV did not correlate with successful PN weaning but did affect the mean duration of PN therapy (7.2 months with ICV v 21.6 months without; P = .03).(ABSTRACT TRUNCATED AT 250 WORDS)

The learning curve associated with laparoscopic antireflux surgery in infants and children.

Laparoscopic fundoplication is an effective method for treating gastroesophageal reflux in infants and children. Some surgeons prefer the traditional open technique and have concerns regarding complications associated with laparoscopic surgery as well as the time length of operation. This report addresses these concerns in a retrospective review of the first 160 consecutive pediatric patients who underwent laparoscopic fundoplication. "Learning Curves" as a function of surgical experience are presented highlighting some of the lessons learned while developing the laparoscopic fundoplication technique.