Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol).

BACKGROUND/PURPOSE: Chest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction. METHODS: A retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up). RESULTS: Five patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years). CONCLUSION: Biologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.

Outcomes of sutureless gastroschisis closure.

INTRODUCTION: A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures. METHODS AND PATIENTS: A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications. RESULTS: In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients. CONCLUSION: Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.

"Stealth surgery": transaxillary subcutaneous endoscopic excision of benign neck lesions.

BACKGROUND: Benign neck lesions are traditionally removed through an overlying incision. The resultant scar can be aesthetically displeasing. We previously reported our experience with a transaxillary subcutaneous endoscopic approach for management of torticollis. We now report a similar technique for removal of benign lesions of the neck. METHODS: The study uses a retrospective review of 5 elective transaxillary endoscopic procedures from March to December 2006. The lesions included an enlarged cervical lymph node, thyroglossal duct cyst, dermoid cyst, ectopic dilated neck vein, and a parathyroid adenoma. Outcome measures included need for conversion, cosmetic outcome, and complications. RESULTS: All procedures were successfully completed using the endoscopic approach. Postoperative pain was controlled with acetaminophen, and all patients were discharged from the hospital the same day. There were no intraoperative complications. The patient who had a thyroglossal cyst removed developed a postoperative seroma that resolved spontaneously. All families were pleased with the cosmetic results. CONCLUSIONS: A transaxillary subcutaneous endoscopic approach can be applied effectively to a variety of benign lesions of the neck, allowing adequate exposure for dissection, and resulting in a quick recovery. Neck scarring is absent, with small scars well hidden in the axilla.

Transaxillary subcutaneous endoscopic release of the sternocleidomastoid muscle for treatment of persistent torticollis.

PURPOSE: Surgical correction of torticollis is occasionally necessary to curtail the facial deformity that can result from this condition. The resultant neck scar can be of suboptimal cosmesis, with consequent psychological distress for the child. We have previously described an endoscopic approach to forehead and brow lesions through scalp incisions. We now describe a transaxillary subcutaneous endoscopic approach to division of the fibrotic sternocleidomastoid muscle. METHODS: This study involved a retrospective chart review of 3 consecutive outpatient procedures (male-to-female ratio, 1:2; age range, 8 months to 7 years) from March to October of 2005. The 2 older patients had established sternocleidomastoid fibrosis, and 1 had complicated torticollis refractory to medical management. All procedures were performed using standard 3-mm-laparoscopic instrumentation through hidden incisions in the ipsilateral axilla. Outcome measures included need for conversion, operative time, cosmetic outcome, and complications. RESULTS: All patients were successfully treated endoscopically. Mean operative time was 50 minutes (range, 45-55 minutes). There were no intraoperative or postoperative complications. All families were pleased with the cosmetic outcome. CONCLUSION: This case series demonstrates the simplicity and effectiveness of a transaxillary endoscopic subcutaneous approach to torticollis.

Doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations in children.

PURPOSE: The authors report their experience with doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations (LMs) in children. METHODS: A retrospective chart review was used to collect data on 11 patients treated with doxycycline sclerotherapy for LMs of the head and neck at our institution since 2003. Radiographic imaging allowed classification of patient LM as macrocystic, microcystic, or mixed according to previously published guidelines. Only patients with macrocystic or mixed lesions were offered doxycycline sclerotherapy. Radiographic imaging and physical examination were used to determine efficacy of treatment. After each treatment, the clinical and radiographic response was characterized as excellent (> or = 95% decrease in lesion size), satisfactory (> or = 50% decrease in volume and asymptomatic), or poor (< 50% decrease in volume or symptomatic). RESULTS: Eleven patients underwent a total of 23 sclerotherapies with an average of 2 treatments per patient (range, 1-4). All 7 patients with macrocystic lesions achieved complete clinical resolution with an average radiographic resolution of 93%. The 4 patients with mixed lesions achieved only partial clinical resolution and an average of 73% radiographic resolution. No patient experienced any adverse effects related to the treatment. At a median follow-up of 8 months, 2 patients (18%) experienced lesion recurrence in the setting of concomitant infection. CONCLUSION: Doxycycline sclerotherapy is safe and effective as a primary treatment modality for macrocystic and mixed LMs of the head and neck in the pediatric population.

Laparoscopic adjustable gastric banding in a morbidly obese 18-year-old with hypertrophic cardiomyopathy.

In this case report, we present an 18-year-old morbidly obese male with complicating hypertensive cardiomyopathy who underwent laparoscopic adjustable gastric band surgery. The patient had multiple comorbidities associated with his obesity, including obstructive sleep apnea, systemic hypertension, asthma, and depression. Given the severity of his underlying cardiac pathology and multiple previously unsuccessful attempts at weight loss with conventional medical and behavioral therapy, the patient opted to proceed with surgical intervention. We present this laparoscopic adjustable gastric banding surgical case to demonstrate the impact of surgical weight reduction on cardiac risk factors in a morbidly obese adolescent, highlighting the viability of this surgery for patients with existing cardiac dysfunction.

National trends in adolescent bariatric surgical procedures and implications for surgical centers of excellence.

BACKGROUND: Bariatric surgery is indicated for severely obese adolescents who have failed nonsurgical treatment. Our objective was to examine national trends in the use of bariatric operations among adolescents. STUDY DESIGN: The Kids' Inpatient Database was used to identify bariatric surgery patients in the pediatric population (age younger than 18 years) for 1997, 2000, and 2003. Patients were identified by procedure codes for bariatric operations with confirmatory diagnosis codes for obesity. Nationally representative estimates of trends in bariatric procedures, patient characteristics, hospital characteristics, and in-hospital complication rates were calculated. We augmented our analysis with the 2003 Nationwide Inpatient Sample, to ascertain hospitals' overall bariatric surgical volume (adolescents and adults). RESULTS: From 1997 to 2003, the estimated number of adolescent bariatric procedures performed nationally increased 5-fold from 51 to 282 (p < 0.01). More than 100 hospitals performed bariatric procedures on adolescents in 2003, most of which (87%) performed 4 or fewer adolescent bariatric operations annually. Operations were predominantly performed in adult hospitals (85%). Although most hospitals had high overall bariatric operation volumes (> 200 bariatric procedures for patients of any age), 39% of adolescent bariatric procedures were performed at lower-volume centers. Patients were predominantly Caucasian (68%) and female (72%), with a mean age of 16 years (minimum age 12 years). In-hospital complications occurred in 6% of patients. There were no in-hospital deaths. CONCLUSIONS: Our findings indicate a recent, rapid increase in the frequency of adolescent bariatric procedures. Most hospitals that performed bariatric procedures on adolescents had limited experience with adolescent bariatric patients, although many of these hospitals appear to have been experienced adult centers with high overall bariatric volume (adolescents and adults). Future research must better clarify the institutional qualifications considered mandatory for treatment of eligible adolescents.

A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome.

OBJECTIVE: The objective of the study was to examine the effect of selective fetoscopic laser photocoagulation (SFLP) vs serial amnioreduction (AR) on perinatal mortality in severe twin-twin transfusion syndrome (TTTS). STUDY DESIGN: This was a 5 year multicenter, prospective, randomized controlled trial. The primary outcome variable was 30 day postnatal survival of donors and recipients. RESULTS: There was no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11 of 20) vs 55% (11 of 20) (P = 1.0, odds ratio [OR] 1, 95% confidence interval [CI] 0.242 to 4.14) or recipients at 30% (6 of 20) vs 45% (9 of 20) (P = .51, OR 1.88, 95% CI 0.44 to 8.64). There was no difference in 30 day survival of 1 or both twins on a per-pregnancy basis between AR at 75% (15 of 20) and SFLP at 65% (13 of 20) (P = .73, OR 1.62, 95% CI 0.34 to 8.09). Overall survival (newborns divided by the number of fetuses treated) was not statistically significant for AR at 60% (24 of 40) vs SFLP 45% (18 of 40) (P = .18, OR 2.01, 95% CI 0.76 to 5.44). There was a statistically significant increase in fetal recipient mortality in the SFLP arm at 70% (14 of 20) vs the AR arm at 35% (7 of 20) (P = .25, OR 5.31, 95% CI 1.19 to 27.6). This was offset by increased recipient neonatal mortality of 30% (6 of 20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality (P = .055, OR 3.025/point) by logistic regression analysis. CONCLUSION: The outcome of the trial did not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.

Laparoscopic Nissen fundoplication during gastrostomy tube placement and noninvasive ventilation may improve survival in type I and severe type II spinal muscular atrophy.

Progressive respiratory muscle weakness with bulbar involvement is the main cause of morbidity and mortality in type I and severe type II spinal muscular atrophy. Noninvasive positive pressure ventilation techniques coupled with laparoscopic gastrointestinal procedures may allow for improved morbidity and mortality. The authors present a series of 7 spinal muscular atrophy patients (6 type I and 1 severe type II) who successfully underwent laparoscopic gastrostomy tube insertion coupled with Nissen fundoplication and early postoperative extubation using noninvasive positive pressure ventilation techniques. The authors measured the length of survival and the frequencies of pneumonia and hospitalization before and after surgery as outcomes of these new surgical and medical interventions. All 7 patients had respiratory symptoms (unmanageable oropharyngeal secretions, cough, pneumonia), difficulty feeding, and weight loss. Six patients had documented reflux via diagnostic testing preoperatively. Five patients were on noninvasive positive pressure ventilation and other supportive respiratory therapies prior to surgery. All 7 patients survived the procedures. By August 2006, 5 patients with type I and 1 with severe type II spinal muscular atrophy were alive and medically stable at home 1.5 months to 41 months post-op. One patient with type I expired approximately 5 months post-op due to obstructive apnea. This case series demonstrates that laparoscopic gastrostomy tube placement coupled with Nissen fundoplication and noninvasive positive pressure ventilation can be successfully used as a treatment option to allow for early postoperative extubation and to optimize quality of life in type I and severe type II spinal muscular atrophy patients.

Outcomes after laparoscopic surgery in neonates with hypoplastic heart left heart syndrome.

BACKGROUND/PURPOSE: Laparoscopy has advanced the care of children for a variety of pediatric surgical diseases. However, complication rates for laparoscopic interventions in neonates with hypoplastic left heart syndrome (HLHS) have not been well described. The purpose of this study is to present the largest reported series of laparoscopic surgery performed in patients with HLHS. METHODS: We conducted a single-institution, retrospective chart review for all neonates with HLHS who underwent a laparoscopic procedure from September 2002 to March 2005. Data regarding patient characteristics, intraoperative monitoring, previous cardiac surgery, perioperative complications, and postoperative mortality were assessed. RESULTS: Twelve patients with HLHS underwent a total of 13 operations during the study period (8 combined Nissen fundoplication and gastrostomy tubes, 3 isolated gastrostomy tubes, 1 Ladd procedure, and 1 combined Nissen fundoplication and gastrocutaneous fistula closure). All cases were completed laparoscopically. Patients had undergone palliative cardiac surgery but were not completely corrected; therefore, they were cyanotic. Perioperative complications were observed in 6 patients (3 gastrostomy tube site infections, 1 small bowel obstruction, 1 postoperative sepsis, and 1 urinary tract infection). There was no mortality in this series. CONCLUSIONS: From this experience, it appears that laparoscopy can be performed safely and with satisfactory outcomes in patients with HLHS. However, a multidisciplinary approach, including the availability of a skilled and experienced cardiac anesthesia team, is believed to be critical to optimize outcomes in these critically ill children.

Experience with 144 consecutive pediatric thoracoscopic lobectomies.

OBJECTIVE: The early experience with the technique and short-term outcomes after pediatric thoracoscopic lobectomy were independently reported by the authors several years ago. This paper updates their combined experience, evaluating the safety, efficacy, and long-term outcomes. METHODS: From January 1995 to May 2005, 144 consecutive patients underwent a thoracoscopic lobectomy. Preoperative diagnoses included cystic adenomatoid malformation/sequestration (n = 112), bronchiectasis (n = 19), lobar emphysema (n = 10), and malignancy (n = 3). Ages ranged from 2 days to 18 years, and weight ranged from 2.8 to 78 kgs. Three or four valved ports were used with a controlled pneumothorax. Single-lung ventilation was used in all cases. Follow-up ranged from 1 to 10 years. RESULTS: All but three procedures were completed thoracoscopically; one was converted to repair an injured upper lobe bronchus during a lower lobectomy, one resulting from bleeding, and another caused by what was believed to be a potentially inadequate margin during the resection of a large tumor. The operating time ranged from 35 to 220 minutes (median, 125). There were 110 lower, 24 upper, and 10 middle lobe resections. There was one intraoperative complication--the compromise of a left upper lobe bronchus. There were four postoperative complications: pneumonia, pneumothorax, empyema, and prolonged chest tube drainage. There were no reoperations. The median duration of hospital stay was 2.8 days. A long-term follow-up revealed no cases of musculoskeletal deformity or weakness. CONCLUSIONS: The current techniques and equipment allow for the complete thoracoscopic resection of pulmonary lobes in any age or size of a child, with low morbidity and no mortality. Long-term outcomes support the efficacy of this technique that spares growing children a thoracotomy that has the potential for late musculoskeletal morbidity.

Use of a prosthetic patch for laparoscopic repair of Morgagni diaphragmatic hernia in children.

BACKGROUND: Morgagni hernias are well suited to laparoscopic repair. A primary suture closure may result in tension on the repair, thereby predisposing the patient to a recurrence. A prosthetic patch (PP) can be used to provide a tension-free repair. In this study, we reviewed our experience with the laparoscopic PP repair of Morgagni hernias in children. METHODS: A retrospective chart review of all patients undergoing a laparoscopic Morgagni hernia repair using a PP was undertaken between November 2002 and January 2006. Outcome measures included age, gender, defect size, use of mesh, and outcome. The time of follow-up was from 6 to 37 months. RESULTS: Seven (7) patients (6 male, 1 female) underwent a laparoscopic repair of Morgagni hernia during this time period. Six (6) patients had a congenital hernia, and 1 patient was thought to have an iatrogenic hernia following a sternotomy for heart surgery. Defect size ranged from 4 to 7 cm in maximum dimension. All operations were completed laparoscopically, no patients presented with recurrence, and no PP complications were encountered. CONCLUSIONS: The laparoscopic repair of Morgagni hernia using a PP can be performed with relative ease and with a positive outcome, and may prevent future recurrence by effecting a tension-free repair.

Minimal access portoenterostomy: advantages and disadvantages of standard laparoscopic and robotic techniques.

PURPOSE: Minimal access portoenterostomy (Kasai procedure) for biliary atresia represents a technically challenging operation. The standard laparoscopic approach yields results comparable to the open technique. After an initial experience with standard laparoscopy, we assessed the potentially superior optics and dexterity of a surgical robotic system for performing portoenterostomy. We reviewed our experience with minimal access portoenterostomy to compare the relative advantages and disadvantages of standard laparoscopic and robotic approaches to biliary atresia. MATERIALS AND METHODS: We reviewed the charts of all patients who underwent either laparoscopic or robotic portoenterostomy at our institution between October 2002 and October 2005. Outcome measures included the need to convert to laparotomy, complications, functional outcome expressed either as the direct bilirubin at most recent follow-up (> or = 3 months) or age at transplant, and density of adhesions at transplant. Surgeons' impressions of the two minimal access modalities were also reviewed. RESULTS: A total of 10 patients underwent minimal access portoenterostomy (7 standard laparoscopy; 3 robotic-assisted). Mean follow-up was 20 months (range, 1-36 months). There were no conversions to laparotomy and no intraoperative complications. There was one port site infection that resolved with antibiotics. Five patients (4 laparoscopic, 1 robotic) had progressed to transplantation at the time of follow-up. At transplant, one patient had mild adhesions and two had dense adhesions. Adhesions were not noted for 2 patients. CONCLUSION: We believe both surgical modalities are feasible from a technical point of view. However, the optical and dexterity advantages of the robotic system were offset by the large instrument size and lack of force feedback.

Clinical resolution of severely symptomatic pseudotumor cerebri after gastric bypass in an adolescent.

Pseudotumor cerebri is a disease characterized by increased intracranial pressure, often manifested by headaches, and occasionally leading to severe visual impairment or even blindness. Most cases in adolescents, as in adults, are associated with obesity. We report a 16-year-old morbidly obese adolescent girl (body mass index 42.3 kg/m(2)) with severely symptomatic pseudotumor cerebri who had progressive visual field deficits and elevated intracranial pressure (opening pressure on lumbar puncture of 50 cm H(2)O) despite intensive medical management and placement of both ventriculoperitoneal and lumboperitoneal shunts. Six months after she underwent gastric bypass surgery, she had lost 43% of her excess body weight and had had near complete regression of her visual field deficits, along with normalization of her intracranial pressures. This case demonstrates the dramatic reversal of symptoms of pseudotumor cerebri with surgically induced weight loss. Gastric bypass should be considered as a treatment option for adolescents with severe and progressive pseudotumor cerebri.

Endoscopic excision of benign forehead masses: a novel approach for pediatric general surgeons.

PURPOSE: Benign tumors of the brow and forehead are commonly managed by pediatric general surgeons by excision through an overlying incision. Cosmetic results in children can be suboptimal. Plastic surgeons have used endoscopic brow-lift techniques for the removal of these lesions. We review our experience after adopting this endoscopic technique in a pediatric general surgery practice. METHODS: We conducted a retrospective chart review of 9 consecutive outpatient procedures (5 girls and 4 boys; age range, 5 months to 12 years) between March and October 2005. Seven patients had lesions located on the lateral brow (left, n = 4; right, n = 3), 1 patient had a lesion on the left mid forehead, and 1 patient had a nasoglabellar cyst. All procedures were performed using endoscopic brow-lift equipment through a single small scalp incision 2 cm posterior to the hairline. Outcome measures included need for conversion, operative time, cosmetic outcome, and complications. RESULTS: All lesions (6 dermoid cysts and 3 pilomatrixomas) were successfully excised endoscopically. The mean operative time was 56 minutes (range, 22-90 minutes). There was no intraoperative or postoperative complication. All families were pleased with the cosmetic outcomes. CONCLUSION: This case report shows that endoscopic excision of forehead masses is a safe and efficacious procedure in the hands of pediatric general surgeons.

Surgical robotics and image guided therapy in pediatric surgery: emerging and converging minimal access technologies.

Minimal access surgery (MAS) is now commonplace in the armamentarium of the pediatric surgeon, and is being applied to a growing list of pediatric surgical diseases. Robot-assisted surgery and image guided therapy (IGT) have evolved as innovative minimal access approaches, and hold the promise of advancing MAS far beyond what is currently possible. The aims of this article are to describe the currently available robotic, and image guided therapy systems, review their present and potential applications, and discuss the future directions of these converging technologies.

Methamphetamine use following bariatric surgery in an adolescent.

Bariatric surgery is increasingly popular as a therapeutic strategy for morbidly obese adolescents. Adolescence represents a sensitive period of psychosocial development, and children with considerable weight loss may experience greater peer acceptance, accompanied by both positive and negative influences. Substance abuse exists as one of these negative influences. We present the case of an adolescent bariatric surgical patient who abused methamphetamines in the postoperative period, with consequent nutritional instability. A concerted effort must be made in the preoperative assessment of adolescent bariatric patients to delineate a history of illicit drug use, including abuse of diet pills and stimulants. Excessive postoperative weight loss or micronutrient supplementation non-compliance should raise a suspicion of stimulant use and appropriate screening tests should be performed. The consequent appetite suppression may manifest with signs of malnutrition such as bradycardia, hypotension, and weakness. Inpatient nutritional rehabilitation and psychiatric assessment should be considered.

Robot-assisted laparoscopic resection of a type I choledochal cyst in a child.

Although the laparoscopic approach to the treatment of complex biliary disease is possible, it is technically challenging. In an attempt to overcome these difficulties, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California) was used to facilitate the minimally invasive treatment of a type I choledochal cyst in a 5-year-old, 22 kg, girl. Complete resection of the choledochal cyst and a Roux-en-Y hepaticojejunostomy were performed using the robotic surgical system. Total robotic setup time (preparation, port placement, docking) was 40 minutes. Total procedure time was 440 minutes. Total robotic operative time was 390 minutes. No intraoperative complications or technical problems were encountered. At 6-month follow-up, the child is doing well with no episodes of cholangitis. Robot-assisted laparoscopic type I choledochal cyst resection appears safe and feasible. The three-dimensional visualization and wristed instrumentation greatly aids in the dissection of the cyst and in the biliary reconstruction.