[Minimally invasive surgery approach for diaphragmatic morgagni hernia in children].

BACKGROUND: Morgagni hernia is the rarest form of diaphragmatic hernia and accounts for less than 6% of all surgically treated congenital diaphragmatic hernias. In recent years, laparoscopic repair is considered to be a suitable and safe procedure for the treatment of Morgagni hernia. MATERIAL AND METHODS: During the last 8 years, 7 patients with Morgagni hernia underwent laparoscopic hernia repair. All patients were male and the age range was between 2.5 to 10 years. All patients were asymptomatic and the hernia was incidentally diagnosed on a routine chest X-ray conducted for unrelated cause. RESULTS: All patients successfully underwent laparoscopic repair of Morgagni hernia. The postoperative course was uneventful in all patients. The children were discharged between 2 to 4 days following surgery. Long term follow-up was uneventful with no recurrency. CONCLUSION: On the basis of our experience as well as others, we consider laparoscopic repair as the procedure of choice for the surgical treatment of Morgagni hernia.

Twelve years of minimally invasive surgery in children and adolescents: a single center experience.

BACKGROUND/PURPOSE: Minimally invasive surgery plays an important role in the daily practice of pediatric surgeons. However, there have been few reports of large series of patients. The aim of this paper is to report our experience over the past 12 years with a broad range of pediatric laparoscopic procedures. METHODS: We performed a retrospective analysis of 1084 minimally invasive procedures conducted in the department of pediatric surgery from June 1992 to March 2004. RESULTS: The mean age of the patients was 14 years (range, 1-19). Seven hundred forty-six operations (69%) were thoracoscopic sympathectomy for hyperhydrosis. Other common operations were high ligation of spermatic vessels (n=98), cholecystectomy (n=65), exploration of nonpalpable testes (n=53), appendectomy (n=55), female adnexal surgery (n=24), and splenectomy (n=13). Thirty miscellaneous procedures included Nissen fundoplication, liver biopsies, diagnostic laparoscopy, Morgani and Bochdalek hernia repair, Swenson procedures, V-P shunt placement, splenic and hepatic cyst removal, thorcoscopy for pleural empyema, treatment of gastric ulcer perforation, and nephrectomy. We reviewed the indications for surgery, the surgical technique, and the outcome for each procedure. All patients in this series were well at follow-up and there was no long-term morbidity. CONCLUSION: Although laparoscopic procedures have gained an integral place in pediatric surgery and are relatively safe, advanced laparoscopic procedures should be developed, practiced and evaluated in dedicated surgical units to ensure a broad base of experience on which to base future decisions and guidelines.

How much of a misnomer is "asymptomatic" intestinal malrotation?

BACKGROUND: Intestinal malrotation is usually observed in the neonatal period with signs of acute high intestinal obstruction due to midgut volvulus. However, malrotation presenting beyond the neonatal period and well into adult life is associated with a variety of atypical and frequently non-specific gastrointestinal symptoms that may often cause prolonged delay in diagnosis and appropriate treatment. OBJECTIVES: To emphasize the difficulty in predicting the risk of midgut volvulus based on age or symptoms, and to recommend surgery in all patients found to have intestinal malrotation even if they are considered asymptomatic. METHODS: We reviewed 41 patients with malrotation treated over a period of 24 years at the Soroka University Medical Center. RESULTS: In our series, 27 patients (66%) had acute midgut volvulus while 14 (34%) had malrotation found during investigation of various long-term gastrointestinal non-specific symptoms. Two patients died of total parenteral nutrition-related sepsis following extensive resection of small bowel. A total of 28 patients was available for long-term follow-up and are asymptomatic. CONCLUSIONS: We recommend elective laparotomy and Ladd procedure in all patients found to have intestinal malrotation. This will prevent the catastrophic results of midgut volvulus and a variety of gastrointestinal symptoms wrongly attributed to other conditions in the span of a lifetime.

Alteration in epithelial permeability and ion transport in a mouse model of total parenteral nutrition.

OBJECTIVE: To investigate the effects of total parenteral nutrition administration on intestinal ion transport and intestinal epithelial permeability. Additionally, to assess the role of interferon-gamma on the total parenteral nutrition-induced loss of epithelial barrier function. DESIGN: Randomized, controlled study. SETTING: Experimental laboratory, University of Michigan Medical School, Ann Arbor. SUBJECTS: Adult wild-type and interferon-gamma knockout mice. INTERVENTIONS: Wild-type mice received total parenteral nutrition or enteral diet (control group) for 7 days. Segments of small bowel from the mice were mounted in Ussing chambers. Short circuit current, as an indictor of active ion transport, was constantly monitored. Epithelial barrier function was assessed by measuring transepithelial resistance and transmural passage of 51Cr-EDTA and 3H-mannitol. Intestinal intraepithelial lymphocyte-derived interferon-gamma protein expression was detected with enzyme-linked immunosorbent assay and confirmed by using intracellular staining and flow cytometry. To investigate the effect of total parenteral nutrition on intestinal ion transport, we used a secretory agonist, carbachol, and an absorptive agent, glucose. MEASUREMENTS AND MAIN RESULTS: Total parenteral nutrition significantly increased small-bowel permeability. Ion transport in the total parenteral nutrition group was significantly increased. To stimulate ion transport, we found that increases in short circuit current induced by carbachol and glucose were higher in the total parenteral nutrition group compared with the control group. Intestinal intraepithelial lymphocyte interferon-gamma protein expression significantly increased with the administration of total parenteral nutrition. Intestinal permeability in interferon-gamma knockout total parenteral nutrition mice was significantly lower than in wild-type mice receiving total parenteral nutrition. CONCLUSION: Total parenteral nutrition has significant effects on intestinal epithelial physiology, stimulating ion secretion and reducing epithelial barrier function. Interferon-gamma appears to play an important role in the loss of the epithelial barrier function that is associated with total parenteral nutrition.

Alteration of intestinal intraepithelial lymphocytes after massive small bowel resection.

BACKGROUND: Intraepithelial lymphocytes (IEL) comprise the inner most layer of the gut immune system, and play a critical role in protecting the host from enteric organisms. Massive small bowel resection (MSBR) is one such clinical condition where patients are at particularly high risk for the development of such enteric infectious complications. Because of this, we hypothesized that the IEL may change significantly after the formation of a MSBR. To address this, a mouse model of MSBR was created and the acute phenotypic and functional characteristics of the IEL were studied. MATERIALS AND METHODS: Mice underwent a 70% mid-small bowel resection. After 7 days, IEL were isolated and analyzed for phenotypic changes by flow cytometry. IEL cytokine expression was performed with semiquantitative polymerase chain reaction techniques. To assess the functional significance of these changes, IEL proliferative response was assessed in vitro.Results. MSBR led to significant decreases in specific IEL subpopulations: CD 44+ (used as a marker of cell maturity); CD 8alphabeta+ (marker of thymic derivation), and CD 69+ (marker of T cell activation). Compared with controls, IEL TNF-alpha mRNA expression increased 84%, while IL-2 and IL-10 mRNA expression decreased by 69 and 72%, respectively. Spontaneous proliferation of IEL in the MSBR group was significantly higher than controls, however, proliferation failed to increase with T cell stimulation.Conclusion. These changes suggest a shift to a more immature and possibly less activated cell population. It is possible that such alterations may play an important role in the increase in enterically derived infections in patients with MSBR.