[Treatment principles and outcome after fractures of the lateral humeral condyle in children]. / Therapieprinzipien und Outcome nach Frakturen des Condylus radialis im Wachstumsalter.

BACKGROUND: Fractures of the lateral humeral condyle with displacement (>2 mm; <2 mm articular gap) require open reduction and stabilization. Non-displaced fractures should be treated conservatively; however, there are difficulties in the differentiation of complete (potentially unstable) an incomplete (stable) articular fractures. The aim of this study was to analyze the frequency of conservative and operative treatment approaches as well as the accuracy of treatment decisions based on fracture stability displayed on repetitive X­rays. MATERIAL AND METHODS: A retrospective data analysis of all lateral humeral condyles in children <16 years old treated between 2005 and 2014 was carried out. The patients were classified according to the fracture stability at the time of the incident (primarily stable or unstable) and after 4 days (secondarily stable or unstable) using conventional X­ray images. RESULTS: A total of 89 fractures of the lateral humeral condyle were treated (mean age 6.4 years, range 0.9-14 years). Of the fractures 52 (58%) were initially not displaced and 37 (42%) were initially displaced. The latter underwent open reduction and stabilization by osteosynthesis (primarily stable). Of the 52 initially not displaced fractures 35 remained stable and conservative treatment in a plaster cast was performed (primarily and secondarily stable). In 8 out of 52 cases a secondary displacement (>2 mm articular gap) occurred after an average of 6 days (range 3-10 days) and operative treatment was initiated (primarily stable and secondarily unstable). No follow-up x­ray could be performed in 2 of the 52 fractures and at the end of treatment the fractures healed with displacement (primarily stable and secondarily unstable). In 7 of the 52 fractures operative treatment was performed although no displacement (primarily stable) was initially documented (overtreatment). The outcome of the whole study cohort was comparable with that described in the literature. CONCLUSION: Treatment decisions in pediatric lateral humeral condyle fractures are based on the primary and secondary fracture stability as observed in staged follow-up radiographs. Stable fractures, whether complete or incomplete, healed with good results after conservative treatment and overtreatment could be avoided. Unstable fractures, whether primary or secondary during the course, need to be recognized as such and operative treatment with a stable osteosynthesis must be initiated.

[Thoracoscopic anatomical lung resection in children]. / Die thorakoskopische anatomiegerechte Lungenresektion im Kindesalter.

There are only few pediatric surgical centers across the world with expertise for minimally invasive anatomical lung resections in children. Between September 2003 and September 2005, 67 children underwent thoracoscopic surgery at the Department of Pediatric Surgery, University Hospital of Tuebingen, Germany. In 19 of these cases a lung resection was carried out, 8 of them had an anatomical lung resection. All patients underwent general anesthesia without selective intubation for the procedure. Intrathoracic pressure with insufflation of carbon dioxide of 1.5 l / min was held at 3-5 mmHg. Two 5 mm ports for video and instruments and one 12 mm port for a stapling device were used. Resected lung specimens were removed from the thorax through an additional 2-3 cm long incision. A bronchoscopy was carried out during surgery in all patients. Median age at operation was 5.6 years (range 3 months-20 years). Median operation time was 150 minutes (range 94-250 min). Conversion to open surgery was performed in 3 cases. This was due to bleeding in one child, due to a stiff lung in another patient with cystic fibrosis and due to a vascular and bronchial malformation in a third child suffering from middle lobe syndrome. There were no postoperative complications. Our preliminary results show, that thoracoscopic lung resections in children can be performed without major complications and excellent cosmetic results. For the necessity of a conversion to open surgery possible reasons may be insufficient intrathoracic overview as well as congenital anomalies of the vascular and / or the bronchial tract. Co-morbidities such as rib-fusion, deformities of the thorax or scoliosis can be avoided using thoracoscopic procedures.

Tracheal surgery in children.

BACKGROUND: The aim of this study is to show that five distinct types of tracheal anomalies should be differentiated with respect to therapy and prognosis. METHODS: The records of 12 infants and children seen over a period of 20 years for different tracheal anomalies such as laryngotracheal stenosis (n = 3), long or short-segment stenosis of the upper (n = 2), middle (n = 6), and lower (n = 1) trachea were reviewed. In addition to these 12 patients with congenital stenosis, 3 other patients needed tracheal resections because of oncologic or traumatic disease: in 2, the trachea was infiltrated by a papillary carcinoma of the thyroid gland and in one, the upper part of the trachea was injured by an oral explosion accident. 25 patients presenting during the same period for other tracheal pathologies including esophagotracheal cleft syndrome (n = 7), tracheomalacia (n = 4), total tracheal agenesis (n = 3), or for placement of a tracheostomy (n = 11) due to other diseases were excluded from this study. RESULTS: There was 1 early death after repair of a laryngotracheal stenosis by cricoid-split and cricoid-splint due to both cerebral hemorrhage and cardiac insufficiency secondary to Fallot's tetralogy. Another child died four weeks after slide tracheoplasty as a result of hypoxic cerebral lesions induced by severe central catheter-related septicemia. One child with therapy-resistant obstructing granulation tissue which developed after a slide tracheoplasty required a tracheostomy. The patient with the tracheal injury died after another accident one year after discharge. All other patients (n = 11) are doing well. CONCLUSIONS: With respect to therapy of congenital and post-intubation tracheal stenosis, four types should be distinguished. Each of these types requires an adequate surgical procedure. The most important postoperative problem in tracheal surgery is the development of granulation tissue. However, the pathogenesis of granulation is still unknown.

Pathogenesis and symptomatology of cholelithiasis in childhood. A prospective study.

QUESTIONS: How may gallstones develop if there is no hemolytic disorder and no malformation or alteration of the gallbladder and cystic ducts? Was there a change in the incidence of stones and the assignment of the patients to different age groups? The literature gives answers to these questions on the basis of only few cases. Therefore, a relatively large prospective database of collected cases during 30 years shall be used to give additional answers. METHODS: The data are derived from 111 children with symptomatic gallstones without hemolytic diseases. 109 of them required operative therapy. They were examined preoperatively and postoperatively maximum during 30 years of follow-up as well according to a defined program. This program includes taking the patient's history, evaluation of clinical, radiological including sonographical examination, exclusion of hemolytic primary diseases, histological investigation of intraoperatively gained specimens of the gallbladder, and the spectroscopic qualitative as well as semiquantitative analysis of stones and bile. RESULTS: (1) The qualitative and quantitative composition of the stones is different in the four age groups. (2) The causes of lithogenesis are different in the four age groups. (3) Children with long-term TPN, after cardiopulmonary bypass operations, after extended small bowel resection, suffering from obesity, and girls using hormonal contraception are at risk of developing gallstones. We recommend to observe these patients by repeated ultrasound controls for gallstone formation during a minimum of 10 years. (4) Malformations and pathological alterations of the gallbladder are rare causes for increased lithogenity. The gallbladder appeared morphologically normal in 61% of patients with symptomatic gallstones. (5) An increased frequency of gallstones during the last 30 years was only observed in the age group under 1 year.

Prognosis of extrahepatic bile-duct atresia after hepatoportoenterostomy.

Clinical and histologic findings from 206 patients operated upon for extrahepatic biliary atresia (EHBA) are analyzed in order to define the prognosis of patients with EHBA. The prospective study took into consideration both initial fibrosis of the liver and the morphology of the porta hepatis (PH) at surgery. Kaplan-Meier survival estimates and statistical calculations demonstrated a relationship between long-term survival and histologic findings in the liver and porta hepatis. The efficacy of HPE is significantly influenced by the morphology of the PH and to a lesser extent by the initial liver fibrosis. Surgery should thus achieve pattern 1 morphology of the PH, but this is problematic because of the close relationship of the vascular and biliary structures in its two lateral zones.

Anatomy of the porta hepatis (PH) as rational basis for the hepatoporto-enterostomy (HPE).

PURPOSE: In a prospective study it was investigated whether and to what degree the morphology of the porta hepatis has a bearing on the early prognosis of children with EHBA. The results will point to consequences of surgery and to the formulation of a rational understanding of the successes and failures of HPE. METHODS: The macroscopy and the microscopy of the liver was studied on native specimen and corrosion preparations of deceased adults, children and embryos. The area potentially draining the bile was determined in excised PH specimen of children with EHBA. The histologically and planimetrically measured areas were correlated to clinical follow-up studies. In order to be able to study exclusively the influence of the PH morphology, the conditions of the intrahepatical structural changes (level of fibrosis, metric and morphic changes of biliary ductules in the Glisson's triads) had to be equal. Under these conditions 61 excised PH specimen were evaluated. The level of fibrosis was determined according to the definition of Schweizer/Müller 1984 (9). RESULTS: 1) Biliary ductules of the PH end in three definable zones according to a regular pattern. 2) Biliary ductules of the PH run in a narrow and immediate relation to the vascular structures. 3) Biliary ductules of the PH are often hidden between the vascular structures of the PH and are not always accessible to preparatory exposure for the anastomosis. 4) The quantity of the bile flow is a significant function of the total area of the biliary ductules secured in the excised PH specimen. 5) Incised biliary ductules at the excision edge may be obstructed again in the scarring of the anastomosis, leading to an early interruption of bile flow. 6) The opening-up of the biliary ductules in the central zone alone is not enough to guarantee a permanent bile flow. Only if intact biliary ductules of the two lateral hepatical lobes are secured, can a positive prognosis be made.

Three-dimensional endosonography of the pelvic floor: an additional diagnostic tool in surgery for continence problems in children.

Three-dimensional endorectal sonography with a specially developed system is able to produce an image of the entire pelvic floor including the sphincter muscles and the rectal wall even in small children. This special system is based on conventional endorectal ultrasound and allows recording of a controlled withdrawal of the axially rotating transducer, creating an image sequence resembling that of a spiral CT-scan; this sequence is digitized off-line and evaluated in a three-dimensional form by a workstation computer. This evaluation has several advantages compared with conventional examination, for example, the complete recording of organs with the possibility of volumetry, construction of arbitrary sections, volume-rendering procedures and the interactive segmentation of organ borders and their three-dimensional visualization. Based on images from this 3D endorectal sonography, the normal anatomy of the pelvic floor that is visible using ultrasound is described, followed by some pathological findings concerning continence surgery. Finally we discuss the advantages and restrictions compared to other examination procedures and the possibilities of technical development.

[Hospital ambulatory pediatric surgery]. / Krankenhausambulante Kinderchirurgie.

Since 1990, we have been conducting ambulatory pediatric surgery in an unit established solely for this purpose, supported by a team of kindergarten teachers, pediatric nurses, anesthesiologists and pediatric surgeons. This prospective investigation includes all ambulatory pediatric operations performed in our department from 1990 to 1995. In this time 3665 infants and children between the ages of 6 weeks and 18 years underwent an ambulatory operation. The ratio male to female was 4.1 to 1. The series consists of 1400 inguinal hernias, 722 inguinal testes, 191 hydroceles/funiculoceles, 75 umbilical hernias, 667 phimoses, 70 meatotomies, 59 hemangiomas, 217 endoscopies and 264 other surgical procedures. Postoperative complications defined as secondary hemorrhage, fever, obvious vomiting, urine retention and laryngospasm upon terminating anesthesia accompanied by subsequent vomiting occurred in 59 (1.6%) of all infants and children. Wound infections were seen in 0.48% (17/3517) of all patients. The recurrence rate for inguinal hernias were 0.79% and 1.12% for inguinal testes. Our experience enables us to summarize that a variety of pediatric operations can be performed today as ambulatory procedures. Nevertheless one must be prepared for the occurrence of complications and always have capacities free for inpatient care where adequate observation and treatment are available. Further improvement is necessary in quality management. In the last 20 years only a few data have been published about recurrence rates after pediatric ambulatory operations for inguinal hernias and inguinal testes. Therefore we started a prospective long- term study.