Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children?

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP. DESIGN: Retrospective analysis of patients treated over a 10-year period. SETTING: Tertiary care children's hospital. PATIENTS: All patients with cholecystectomy for biliary disease. INTERVENTIONS: Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice. MAIN OUTCOME MEASURES: Incidence and complications of choledocholithiasis and frequency of ERCP. RESULTS: One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications. CONCLUSIONS: This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.

In-line image projection accelerates task performance in laparoscopic appendectomy.

BACKGROUND: In laparoscopy, the monitor usually is placed at or above eye level across from the operating surgeon. Position of the endoscopic image at hand level has been shown in a laboratory model to facilitate task performance. The authors tested the hypothesis that in-line image projection reduced operating time for a standardized procedure. METHODS: Children undergoing laparoscopic appendectomy were assigned randomly according to video image position: (1) at the top of the laparoscopy tower in front of the surgeon ("overhead") or (2) on a screen placed on the patient's abdomen ("in-line"). Operating time was recorded for each operation, and patients were stratified according to severity of appendicitis and training level of the operating surgeon. Statistical analysis was performed using Student's t, chi2 tests, and analysis of variance with post-hoc Fisher test (P <.05. significant). RESULTS: One hundred eight children, aged 2 to 17 years, underwent a laparoscopic appendectomy during a 26-month period. Fifty-four were assigned to the in-line projection screen and 54 to the overhead monitor. Operating time was significantly shorter (P =.013) when in-line projection was used (46.8 +/- 10.2 v. 52.2 +/- 15.1 minutes with overhead monitor). By analysis of variance (ANOVA) the only factors that significantly affected operating time were use of in-line projection (P =.030), severity of appendicitis (P =.002), and training level of the operating surgeon (P =.047). CONCLUSIONS: Placing the endoscopic image in the same field as the surgeon's hands decreases operating time by 10%, even for procedures that, like appendectomy, do not require complex suturing skills. This decrease in operating time occurs independently of the surgeon's level of proficiency or the degree of difficulty of the operation.

Benefits of term delivery in infants with antenatally diagnosed gastroschisis.

OBJECTIVE: To test the hypothesis that term gestation offers the best outcome. The relationship between gestational age and the extent of bowel injury in fetuses with gastroschisis is a matter of debate. Early delivery and cesarean delivery have been recommended to limit intestinal damage, but their benefits are unclear. METHODS: Data on all patients with gastroschisis seen at our institution from 1991 through 2001 were included. Patients were compared based on gestational age: less than 35 weeks, 35-37 weeks, and term (more than 37 weeks) with regard to age at definitive closure, age at first and full feedings, and hospital stay. Statistical significance (P <.05) was determined by analysis of variance and chi(2) analysis. RESULTS: Of the 57 patients, 19.3%, 43.8%, and 36.9% were born at less than 35 weeks, 35-37 weeks, and more than 37 weeks, respectively. Age at definitive closure was significantly higher at 35-37 weeks (5.9 +/- 4.6 days) than at more than 37 weeks (1.5 +/- 2.3 days) and less than 35 weeks (2.6 +/- 2.5 days) (P <.05). A prosthetic pouch (silo) was used more often at 35-37 weeks than at more than 37 weeks or less than 35 weeks (P =.03, chi(2)). Age at first (P =.04) and full feedings (P <.01) and length of hospitalization (P <.01) were all significantly higher at 35-37 weeks than at more than 37 weeks. CONCLUSION: Based on a homogeneous cohort of patients in whom gastroschisis was diagnosed antenatally, term delivery results in earlier closure of the defect and shorter time to full feedings. The benefit of early delivery postulated by others cannot be substantiated.