Primary carcinoma of the gallbladder. The role of adjunctive therapy in its treatment.

Of forty-three patients with carcinoma of the gallbladder discovered ih a twenty-five year period (during which 10,349 patients were diagnosed as having cholelithiasis), eighteen patients (42 per cent) had no obvious tumor outside of the gallbladder at the time of operation, nineteen patients (44 per cent) had local spread of the disease, and six patients (14 per cent) had abdominal carcinomatosis or distant metastasis. In the twenty-one patients who underwent surgical therapy for cure of their disease, the five year survival rate was 33 per cent. The more extensive surgical procedures (other than cholecystectomy alone) did not significantly increase survival. Neither the duration of the symptoms nor the pathologic type of the tumor altered the eventual outcome. No patients with tumor outside the gallbladder at the time of operation survived longer than two years. Compared to those who did not receive it, the fifteen patients treated postoperatively with adjunctive therapy (radiation therapy or chemotherapy or both) lived longer and also were significantly better palliated when tumor outside of the gallbladder was found at the time of operation. From these findings, the routine use of adjunctive therapy is recommended in all patients with disease outside of the gallbladder and serious consideration should be given to its use in all patients found to have carcinoma of the gallbladder.

Evaluation of hematologic abnormalities in the nonbleeding postoperative patient.

With a seriously ill postoperative patient, selecting the best course of action may be difficult when laboratory data suggest hematologic abnormalities. If an Afro-American is to undergo major surgery, simple postoperative screening procedures are available for certain hereditary erythrocyte abnormalities. Acute hemolysis, from any cause, may mimic advanced liver disease. Bleeding into closed body spaces, with erythrocyte destruction secondarily, may mimic generalized hemolysis. One basic premise is always to review the medications being administered; many drugs may induce granulocytopenia or anemia. Because there is a compensatory increase in erythrocyte 2,3-diphosphoglycerate content that increases oxygen release to the tissues in the normovolemic anemic patient, less frequent use of blood transfusion is possible in these patients. Healing will continue even when the packed red cell volume is 25 per cent.

Utility of the cervical spine radiograph in pediatric trauma.

To determine the utility of the routine cervical spine radiograph, we reviewed all cervical spine radiographs obtained in pediatric trauma patients over a 2 1/2-year period at the Childrens Hospital of Los Angeles. Records of patients admitted with a documented cervical spine injury over a 20-year period were also reviewed. One hundred eighty-seven children had at least one cervical spine radiograph. Forty-six patients (25 percent) required at least one repeat study in an attempt to see all 7 vertebrae. Thirty-eight children (20 percent) had a second radiograph and 8 patients had a third study, all of which showed no injury. There was only one fracture seen during the 2 1/2-year time period. Of the 16 children admitted over the 20-year period, only 3 sustained an injury below the fourth cervical vertebra (C4), and all were over 8 years of age. All patients with cervical spine injury were either comatose or had symptoms referable to the neck. We conclude that the routine cervical spine radiograph in pediatric trauma is a very low-yield test.

Management of traumatic peripheral vein injuries. Primary repair or vein ligation.

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.

Traumatic arterial injuries of the upper extremity: determinants of disability.

Of 233 patients who sustained vascular injuries during a 13 year period, 99 had involvement of the upper extremity. The primary site of upper extremity injuries was the brachial artery (43 patients), and the primary cause of injury was gunshot wounds. The majority of the vascular injuries were repaired primarily. Nerve injuries occurred in 56 of the patients, and they were the primary cause of disability. Edema and infection were not significant determinants of limitations in function. Gunshot wounds to the brachial artery resulted in the highest incidence of disability and limb loss.

Clinical information systems.

Clinical information systems are the computer and information systems used by health care personnel to facilitate patient care. These systems have evolved from financial systems to true patient care systems with variable levels of functionality. Early systems provided laboratory and radiology results, and modern systems now provide copies of the radiology images and decision support for therapeutic orders. The rapidly changing technological infrastructure has created barriers to implementation of the electronic medical record, while coding schemes continue to be refined to enable data access and aggregate data analysis. Further refinement of clinical information systems is required before the potential value of these systems is realized in the clinical management of patients.

Facial palsy: interpretation of neurologic findings.

A review of the otoneurologic findings in 500 patients with facial paralysis revealed their importance for diagnosis, prognosis, and understanding the pathophysiology of Bell's palsy. Diagnosis. The presence of simultaneous bilateral palsy, facial paralysis associated with lateral rectus palsy, slowly progressive facial weakness with or without hyperkinesis, and facial paralysis that showed no recovery after six months excluded Bell's palsy from the diagnosis. Ipsilateral recurrent palsies were another indication to suspect an underlying cause, since a tumor of the facial nerve caused the paralysis in 30% of the patients with this finding. Signs such as intact forehead movement, alterations in facial sensation, and corneal hypesthesia--although often associated with lesions in the cerebral cortex, cerebellopontine angle, or internal auditory canal--were also found in patients with Bell's palsy. Prognosis. A spontaneous complete recovery following Bell's palsy occurs in about 70% of the patients; but in the presence of a dry eye or dysacousis, the prognosis for a complete recovery drops 10 and 25%, respectively. Pathophysiology. It is proposed that the wide range of neurologic findings associated with Bell's palsy is due to a viral polyneuropathy. This is a disorder that primarily involves sensory nerves, and the facial motor deficit results from involvement of the sensory fibers carried with the facial nerve within the fallopian canal.

Natural history of bell's palsy: the salivary flow test and other prognostic indicators.

Fifty-one patients with Bell's palsy were evaluated within two days of onset and followed for six months without surgical intervention or effective medical treatment in order to observe the natural history of the disease. Sixty-three percent had a complete return while 37 percent had incomplete return. Age, the presence of pain, and taste alterations had no prognostic value. The progression of the palsy, response to maximal stimulation and salivary flow testing were approximately 80 percent accurate in predicting outcome. The salivary flow test was the most useful prognostic indicator since salivary flow became reduced within two days of onset in the patients likely to develop denervation while the other tests did not become altered until 3 to 14 days after onset. In patients with Bell's palsy, the salivation test seems to be the only method capable of predicting denervation before it begins; therefore, it should be ideal for selecting patients for appropriate treatment.

The use of steroids in Bell's palsy: a prospective controlled study.

A prospective, controlled, double-blind study was designed to evaluate the effect of steroid treatment on the natural history of Bell's palsy. Fifty-one patients were included in the study between 1972 and 1974. The patients were evaluated and started on treatment within two days of onset of Bell's palsy and followed for six months. Treatment was given in randomized double-blind fashion and consisted of either vitamins or a total of 410 mg of prednisone plus vitamins in descending doses over 10 days. The recovery of facial motor function was determined by three physicians who had no knowledge of the treatment received by the patients. They examined photographs of the patients taken six months after onset of paralysis in eight positions of facial function and categorized them as to complete fair, or poor recovery of facial function. These results of this evaluation were submitted to the biostatistician who broke the treatment code. The results of this study demonstrate no statistically significant beneficial effect of steroid therapy upon recovery from Bell's palsy. Factors considered included the patients' age, sex, the presence of pain, ageusia, hyperacusis, diabetes, hypertension, the progression and degree of palsy, the results of nerve excitability and salivary flow tests, and the time at which recovery was first noted or became complete. Bell's palsy remains without a proven efficacious treatment.

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.

Successful management of trifurcation injuries.

Vascular injuries to the distal popliteal artery and its primary division(s) (trifurcation) combined with fracture(s) were analyzed for the years 1978 to 1983 at the Charity Hospital of Louisiana at New Orleans and Tulane Medical Center affiliates. This article does not include reports of isolated popliteal artery injuries. Thirty-six male patients with a mean age of 24 (16 to 47) years experienced 20 tibiofibular fractures and 16 tibial plateau fractures. Twenty-four injuries were secondary to penetrating trauma; the remaining 12 vascular injuries were the result of blunt trauma. All patients were angiographed preoperatively, resuscitated, treated with tetanus toxoid and antibiotics, and brought to the operating room in an average of 95 (30 to 244) minutes from entry to the emergency departments. Eight (22%) definitive below-knee amputations (BKA) (six [17%] with blunt trauma) and 28 (78%) reconstructive procedures were done initially. Twenty-four of the 28 (86%) patients had associated venous injury; 16 were repaired. Twenty of the 28 (71%) patients received fasciotomies There were eight late amputations in addition to the eight early definitive BKA; five secondary to related neurologic injury. Twenty of the 28 (71%) patients had successful repair of their arterial injury and total rehabilitation.

Pseudocysts of the pancreas in children.

Sixteen children with pancreatic pseudocysts were treated from 1965-1988. Blunt trauma was the etiology of pseudocyst formation in 69 per cent of children with 50 per cent resulting from the abdomen impacting bicycle handlebars. Chronic pancreatitis is an uncommon cause of pseudocyst formation in children. Medical therapy is directed towards reduction of pancreatic stimulation and nutritional support, which are maintained through pseudocyst resolution or maturation. Pseudocysts spontaneously resolved in 25 per cent of patients. Complications occurred in 25 per cent during nonoperative management. Children may safely undergo internal drainage earlier than adults (3-4 weeks vs 6 weeks). Internal drainage by cystoenterostomy was curative in eight patients. Persistent fistula drainage developed for five weeks in one patient who had surgical external pseudocyst drainage. One patient required distal pancreatectomy for a transected pancreatic duct. Spontaneous resolution of psseudocysts while on medical therapy is more frequent in children than in adults, and major complications (abscess formation, hemorrhage, and fistula formation) are usually not encountered. Pseudocyst rupture is the major complication of conservative management. We had no pseudocyst recurrences and 11 of 12 children treated surgically were discharged home within ten days of operation.

Evidence-based practice in pediatric surgery.

BACKGROUND/PURPOSE: The current medical environment demands the provision of quality healthcare at an affordable cost. Both payors and regulators are committed to lowering cost through initiation of best practice strategies that include practice guidelines, clinical pathways, and standards of care. The only practical way to join this debate is through the use of objective, unbiased clinical data. This study was undertaken to review the current state of the pediatric surgery literature and its value in determining best clinical practice. METHODS: The National Library of Medicine Medline database was accessed using the Ovid Internet client software. All references, abstracts, and keyword indexes from the core pediatric surgery literature, the Journal of Pediatric Surgery, the European Journal of Pediatric Surgery, Pediatric Surgery International, Zeitschrift fur Kinderchirurgie, and Seminars in Pediatric Surgery were downloaded and reviewed. Search criteria were defined to identify prospective, randomized, controlled studies. References were then categorized as case reports; retrospective case series; prospective case series; randomized, controlled studies; laboratory studies; review articles; or miscellaneous studies. RESULTS: As of March 1, 1998, there are 9,373 references, excluding citations of letters or comments, contained in the core pediatric surgery literature, as provided through Medline. Of these, 485 were identified as studies for review, possible prospective case series or prospective, randomized, controlled studies. After review, 34 studies (0.3%) were classified as prospective, randomized, controlled studies, whereas 139 (1.48%) were classified as prospective studies. There were 3,241 (34.6%) case reports, 5,619 (59.9%) retrospective case series, 1,109 (11.8%) laboratory studies, 195 (2.1%) review articles, and 36 (0.3%) miscellaneous studies that did not fit into other categories. When analyzed by decade of publication, prospective studies and prospective, randomized, controlled studies (n = 173) numbered 103 in the 1990s, 63 in the 1980s, and seven in the 1970s. CONCLUSIONS: There is a paucity of scientifically rigorous data on which to base clinical practice in pediatric surgery. The increasing numbers of prospective, case-controlled studies or the more sound prospective, randomized, controlled trials in the 1990s suggests that pediatric surgeons are aware of the need to generate unbiased data to support current clinical practice and the development of practice guidelines. Limitations exist in conducting prospective, randomized, controlled trials because of the rare nature of many pediatric surgical conditions and the lack of clinical "equipoise" over available treatment options. The authors encourage the use of multiinstitutional trials and the prospective, randomized, controlled study methodology to develop data that can be used to guide clinical practice in our evolving healthcare environment.

Gluteus maximus augmentation for the treatment of fecal incontinence.

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.

Sequential intestinal lengthening procedures for refractory short bowel syndrome.

Better understanding of the long-term delivery of parenteral nutrition (PN) in neonates and children has increased the survival for patients who have neonatal short bowel syndrome. Most infants with short bowel syndrome experience progressive enteral adaptation and are weaned from PN. This report describes the authors' clinical experience with nine infants and children who had refractory short bowel syndrome; single or sequential procedures were performed to lengthen the small bowel. Gut lengthening procedures used included a small bowel nipple valve constructed distally, to provide temporary partial obstruction and thereby induce dilatation and lengthening of the proximal small intestine (six patients). Bianchi's technique was used in three patients primarily and in six others after the bowel had been dilated and lengthened by the nipple valve. Kimura's gut lengthening technique was used in one patient after the small bowel had spontaneously become dilated subsequent to a Bianchi procedure. In all, 16 lengthening procedures were performed on the nine patients. Preoperatively, the nine patients tolerated less than 10% of their caloric intake enterally, with no evidence of improvement for a minimum of 6 months. Small bowel segments ranged from 6 to 92 cm originally and were increased an average of 2 1/2 times the original length. Two patients have been totally weaned from PN. For the patients whose lengthening procedure was performed more than 1 year ago, the percentage of enteral caloric intake averages 50%. One of the patients was profoundly impaired neurologically and was not resuscitated from an apneic episode. Another patient died in his sleep of unknown causes 1 year after intestinal lengthening.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary laparoscopic pull-through for Hirschsprung's disease in infants and children.

Between November 1993 and September 1994, 12 primary laparoscopic colon pull-through procedures were performed in infants and children. The patients' ages ranged from 3 days to 6 years. The primary diagnosis in all 12 patients was Hirschsprung's disease. All children had their operations without construction of preoperative or postoperative colostomy. Three 5-mm abdominal wall ports were used for access to the peritoneal cavity. The sigmoid colon and proximal rectum were mobilized laparoscopically. A submucosal sleeve was developed transanally to meet the dissection from above. The colon was then pulled down in continuity, divided above the transition zone, and secured to the anal mucosa 5 to 10 mm above the pectinate line. Mean postoperative stay was 4 days. Laparoscopic visualization provides clear delineation of pelvic structures even in small infants. Laparoscopic pull-through requires no more time than similar open procedures, averaging just over 2 hours. The morbidities associated with colostomy formation and closure and the inconvenience of colostomy care are avoided with a one-stage technique. These benefits combined with the advantages of minimally invasive surgery make primary laparoscopic pull-through a potential advance in the surgical treatment of Hirschsprung's disease.

Comparison of open and laparoscopic gastrostomy and fundoplication in 120 patients.

The rapid development and incorporation of minimally invasive surgical techniques has abruptly changed adult surgical practices. These minimally invasive procedures are now being successfully applied to pediatric surgical problems. The anticipated benefits of these techniques include less postoperative pain, quicker return of bowel function, shorter hospital stay, and lower hospital costs, with a quicker return to normal activity. This report compares the first 60 infants and children to undergo laparoscopic gastrostomy and/or fundoplication at our institution with the same number of patients that underwent these procedures in the traditional open fashion. The two groups were similar with respect to age, sex, concurrent illness, presenting symptoms, neurological status, and procedures performed. Patients in the laparoscopic group were found to have shorter mean hospital and postoperative stays and tolerated feeding earlier. The mean hospital stay was 13.8 days for the laparoscopic group versus 16.4 days in the open group. The mean postoperative stay was 6.8 days for the laparoscopic group versus 10.7 days for the open group. The mean postoperative day on which feeding was tolerated was 2.3 in the laparoscopic group versus 4.8 in the open group. Postoperative complications were similar between the two groups. These results seem to reflect the less traumatic nature of the laparoscopic procedures as compared with the open procedures. Laparoscopic fundoplication and gastrostomy is an attractive alternative to open fundoplication and gastrostomy in infants and children.

Duplication of the hepatopancreatic bud presenting as pyloric stenosis.

Duplication of systemic organs is not a frequent finding. We report the occurrence of duplication of the hepatopancreatic bud with presence of mature hepatic and pancreatic tissue in a nine-day-old girl who presented with intestinal obstruction mimicking infantile hypertrophic pyloric stenosis.

Blunt cardiac injury in children.

Thirty-nine children admitted to the pediatric intensive care unit with multiple injuries from blunt trauma underwent serial EKGs, determination of creatinine phosphokinase (CPK) isoenzymes, echocardiography, and radionuclide angiography studies. Motor vehicle injuries were responsible for 83% (32 of 39) of admissions, the remainder (7 of 39) caused by falls from heights. Thirteen children sustained serious (Modified Injury Severity Score [MISS] greater than 25) multiple system injury. Chest injuries were sustained by 12 children, nine being serious thoracic injuries (MISS chest score greater than 2). Three children (7.7%) showed elevations of MB fraction of CPK isoenzymes in addition to EKG abnormalities and/or ejection fraction depression on radionuclide angiography and were considered to have sustained cardiac contusion. Eight other children (20%) had normal or borderline elevation of CPK-MB fraction and EKG abnormalities combined with abnormal echocardiograms or radionuclide angiograms, and were considered to have sustained cardiac concussion. An additional 14 children (36%) had EKG or radionuclide angiography abnormalities alone. Two children required lidocaine therapy for cardiac irritability manifesting as multifocal PVCs and ventricular tachycardia. Based on this study, a comprehensive diagnostic evaluation of the heart in all children sustaining multiple injuries from blunt trauma cannot be justified. Continuous cardiac monitoring should be initiated in the emergency room and maintained throughout intensive care unit confinement to identify transient dysrhythmias. In patients with significant dysrhythmias and in those with obvious thoracic injuries serial EKG and cardiac isoenzyme assay should be obtained. Dysrhythmias should be man-aged with appropriate anti-arrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Broviac catheter insertion: operating room or neonatal intensive care unit.

We reviewed the records of all infants hospitalized in the neonatal intensive care unit (NICU) who underwent insertion of a Broviac catheter from July 1, 1984 through August 30, 1985. Eighty-six catheters were inserted in 81 patients. Thirty-one catheters were inserted in the NICU and the remainder were inserted in the operating room (OR). The patient's average weight at the time of catheter insertion was the same in both groups. Fifty-two of the 55 OR catheters (95%) were inserted in the external or internal jugular vein while only 68% of the NICU catheters were placed in the jugular veins. Six of the NICU catheters (19%) and 11 of the OR catheters (20%) developed catheter-associated sepsis with positive blood cultures. The infection rate per catheter day was similar in both groups as was the incidence of catheter occlusion. The NICU catheters were in place for an average of 51 days, and there was an average 46 day lifespan for the OR inserted catheters. Broviac catheter insertion can safely be performed in the NICU without an increase in morbidity. Broviac catheter insertion in the NICU is less costly and saves transportation of the sick neonate to the operating room.