Laparoscopic Cystogastrostomy in Children with Pancreatic Pseudocysts: A Preliminary Experience of Eight Cases.

Introduction: Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center. Materials and Methods: Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach. Results: Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5-55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence. Conclusion: LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome.

Transureteroureterostomy as an adjunctive antireflux procedure in children undergoing bladder augmentation for neurogenic bladder with major reflux.

INTRODUCTION: Transureteroureterostomy (TUU) provides urinary drainage of both renal systems to the bladder via a single ureter and is useful in selected situations of complex urological reconstructions. Herein we discuss its use, advantages and complications in children with neurogenic bladders and high-grade (4/5) reflux who have undergone augmentation cystoplasty. PATIENTS AND METHODS: Children with neurogenic bladder complicated by unilateral or bilateral high-grade vesicoureteric reflux (VUR), who underwent TUU along with augmentation cystoplasty (BA), were selected from two institutions. Eighteen children with an average age of 5 years at presentation were identified from a retrospective chart review. RESULTS: All had bilateral hydroureteronephrosis (HUN) of which there were 30 refluxing megaureters. While BA reduced bladder pressure, VUR was managed by refluxing to non-refluxing TUU in six cases with unilateral VUR and unilateral reimplantation with TUU to the reimplanted ureter in 12 cases of bilateral VUR, thus minimizing reimplantation to 12 of 30 ureters. The average time of follow-up was 51 months. Follow-up cystograms showed complete resolution of VUR in all. HUN improved/stabilized in all but one child. Serum creatinine remained normal in all but two cases. Other advantages of TUU include the use of the distal ureter as a catheterizable channel and ease of undiversion when the ureter has been diverted as a ureterostomy. An unusual complication of a TUU site stricture is discussed and the innovative technique of using a cecal patch to salvage the anastomosis is detailed. CONCLUSION: We conclude that a TUU is a safe and useful adjunctive procedure in children undergoing BA for neurogenic bladder with high-grade VUR, minimizing the need for ureteric reimplant in an unhealthy bladder.

Outcome of end cutaneous ureterostomy (ECU) as a non conservative option in the management of primary obstructive megaureters (POM).

INTRODUCTION: Primary obstructive megaureters (POM) can be treated with one of the following options: conservative management with antibiotic chemoprophylaxis and active observation of the hydroureteronephrosis (HUN) until suspicion of renal deterioration; refluxing/non-refluxing ureteric reimplantation with antibiotic suppression; temporary double-J stenting; endoscopic balloon dilatation; endoureterotomy; and end cutaneous ureterostomy (ECU). OBJECTIVE: To study the profile of patients with POM and assess the efficacy, safety and outcome of ECU as an interim procedure. METHODS: A retrospective review was performed of patients who underwent ECU for POM between January 2004 and December 2014. Demographics, surgical details, and outcomes were studied. RESULTS: A total of 25 patients (19 males, six females) underwent ECU of 25 renal units for POM at a mean age of 7 months (range 23 days to 2.5 years). Of these, nine had presented with radiological worsening of antenatally detected HUN, 12 had symptoms (urosepsis in nine and palpable hydronephrosis in three), three had a solitary kidney in renal failure, and one had incidentally diagnosed renal cortical thinning as shown in Table below. Following diversion, renal failure had resolved in all, and febrile urinary tract infection (UTI) developed in one while awaiting reimplantation. Undiversion was performed in 21/25 patients at a mean duration of 12 months after diversion and a mean age of 19 months. In these, the ureteric size had decreased significantly at reimplantation. In 4/25, undiversion was not performed due to loss of follow-up in two and a subsequent nephrectomy in two. Two out of 21 developed febrile UTI after undiversion. The overall mean follow-up period was 34.2 months (n = 25), while the mean follow-up after undiversion was 41.5 months (n = 21). There was no incidence of stomal complications. CONCLUSIONS: End cutaneous ureterostomy was a safe and effective temporary procedure for the treatment of progressive primary obstructive megaureters.

Laparoscopic cholangiogram in biliary atresia: a refinement in the gallbladder hitch technique.

INTRODUCTION: The study describes a refinement in the gallbladder hitch stitch and assesses the value of the laparoscopic cholangiogram in children with suspected biliary atresia. METHODS: Twenty children with neonatal jaundice and no drainage as shown on the HIDA scan underwent a diagnostic laparoscopy through an umbilical 5 mm port. A 3 mm laparoscopic needle holder inserted through a 3.5 mm port to the left of the umbilicus was used to hitch the gallbladder to the abdominal wall. The stylet of a large bore 16F IV cannula then was used to penetrate the gallbladder to perform the laparoscopic cholangiogram. RESULTS: There was no need for conversion in all 20 children by this technique. Patent biliary anatomy was demonstrated in 11 children (11/20). These children had no further procedures. In 3 (3/20) children, the common bile duct was demonstrated, while the hepatic ducts were not. These children had a laparotomy for Kasai procedure after an open cholangiogram with a vascular bulldog clamp on the CBD confirmed the finding. Six (6/20) had no demonstrable patency; 3 had it confirmed when the abdomen was opened for the Kasai procedure; only those proceeding to Kasai portoenterostomy (3 hepatic duct atresia, 3 complete biliary atresias) had an epidural catheter placed by the anesthetist. The remaining 3 had no further procedure performed due to the advanced nodular liver with ascites and evidence of portal hypertension. CONCLUSION: The findings of laparoscopic cholangiogram were confirmed in all six children who underwent laparotomy for Kasai procedure. The laparoscopic cholangiogram using gallbladder hitch reliably demonstrates a patent biliary system (11/11) and was valuable in avoiding further invasive procedures in 70% (14/20) of babies.