Thoracoscopic thymectomy for myasthenia gravis in children.

The technique for thoracoscopic in children is described. The average operating time is under 2 hours, and the procedure appears to be safe and effective.

Analysis of the costs of surgery for Hirschsprung's disease: one-stage laparoscopic pull-through versus two-stage Duhamel procedure.

The purpose of this report is to evaluate the cost-effectiveness of a single-stage laparoscopic pull-through for Hirschsprung's disease compared to the traditional two-stage Duhamel procedure. In this series of 33 children, the length of hospitalization (2.5 +/- 3.5 vs 10.6 +/- 3.9, p < 0.01), cost (19,088 +/- 13,075 vs 34,110 +/- 19,443, p < 0.05), and complications were all significantly less with the laparoscopic assisted pull-through compared to the more traditional open approach.

Early definitive intervention by thoracoscopy in pediatric empyema.

PURPOSE: Nineteen children had early thoracoscopic intervention for empyema between 1992 and 1997 at the LeBonheur Children's Medical Center. The authors have evaluated the results of this treatment. METHODS: Thoracoscopic intervention was performed at the fibrinopurulent state of empyema. An irrigating laparoendoscope was inserted, loculi were disrupted, debris was evacuated, and a chest tube was passed through the port site. RESULTS: The patients were aged between 11 months and 16 years (mean, 6.5 years). The etiology of the empyema was parapneumonic in 17, and there was one case each of perforated appendicitis and mediastinal histoplasmosis. They underwent thoracoscopy at a mean of 4.6 days after hospital admission (range, 1 to 12 days). Chest tubes were removed at 1 to 5 days (mean, 2.9 days) after operation, and resolution of fever occurred at 1 to 9 days (mean, 3.8 days) postoperatively. Patients were discharged home between 4 and 10 days (mean, 6.1 days) postoperatively, and the mean hospital stay was 10.3 days (range, 5 to 21). There were no complications. The surgical technique was simple and well tolerated, requiring few disposable items, and the mean operating time was 77 minutes. CONCLUSIONS: Thoracoscopy eliminated the morbidity of thoracotomy and the discomfort and expense of prolonged chest tube drainage. Thoracoscopy may be used as early first-line therapy in a majority of pediatric patients with fibrinopurulent empyema.

Interval appendectomy for perforated appendicitis in children.

To determine the efficacy, safety, and cost of managing perforated appendicitis with intravenous antibiotics followed by an interval appendectomy, the charts of 87 children with ruptured appendicitis were retrospectively reviewed. These patients were treated with intravenous fluid resuscitation and antibiotics (consisting of clindamycin and ceftazidime) and underwent appendectomy, either on that admission (n = 46) or as a delayed interval procedure (n = 41). Antibiotics in all cases were discontinued either at home or in the hospital after the child was a febrile for 48 hours with normal white and differential blood cell counts, and the two groups were compared. Seven patients (17%) "failed" the interval appendectomy protocol. All but one "failure" was due to the development or persistence for >72 hours of a bowel obstruction. The data are described below as percent or mean +/- 1 standard deviation. [table: see text] We conclude that antibiotics and interval appendectomy is a safe effective alternative for the management of perforated appendicitis. When successful, hospitalization, charges, and morbidity are less with this approach. A persistent bowel obstruction for 72 hours is an indication to proceed with appendectomy on admission.

Acute appendicitis: as a predisposing factor for acute glomerulonephritis--report of two cases.

This is a review of two children who developed acute glomerulonephritis (AGN) following acute gangrenous appendicitis (AGA) with periappendicular collections. The first patient presented with AGN during the course of appendicitis. The second patient developed AGN after appendectomy. Both patients did not have any other predisposing factors. AGN resolved in both patients after massive intravenous antibiotics. This is the first report of acute appendicitis as a predisposing factor for AGN.

Unusual case of Meckel's diverticulum: a case report and review of an atypical form of presentation.

This is a review of a child who developed symptomatic anemia secondary to a huge Meckel's Diverticulum (MD). The patient presented with multiple complications, such as: neoplasia, occult chronic bleeding, giant size MD, partial intestinal obstruction and severe symptomatic anemia. There was complete resolution of the condition after resection and ileo-ileal anastomosis. After revision of the literature, this case is the first report of MD occurring concomitantly with such a myriad of signs and symptoms.

Laparoscopic pyloromyotomy: a safer technique.

A modified technique of laparoscopic pyloromyotomy was used to treat infantile hypertrophic pyloric stenosis. Introducing a 5-mm periumbilical port for visualization, two stab wounds are made on either side laterally to directly insert 2.7-mm instruments for manipulation. From the left, the stomach is grasped - not the duodenum! From the right, an inexpensive disposable arthroscopy knife is used to incise the serosa and begin the myotomy, which is completed with a laparoscopic spreader until the muscle is separated sufficiently to relieve the obstruction. Twenty-nine children treated with laparoscopic pyloromyotomy were compared to 125 children treated with the conventional open Ramstedt pyloromyotomy. There were no statistically significant differences in the presentation or results between groups, suggesting that the laparoscopic technique is a safe and equal alternative.

Unusual case of Meckel's diverticulum: a case report and review of an atypical form of presentation

This is a review of a child who developed symptomatic anemia secondary to a huge Meckel's Diverticulum (MD). The patient presented with multiple complications, such as: neoplasia, occult chronic bleeding, giant size MD, partial intestinal obstruction and severe symptomatic anemia. There was complete resolution of the condition after resection and ileo-ileal anastomosis. After revision of the literature, this case is the first report of MD occurring concomitantly with such a myriad of signs and symptoms

Acute appendicitis: as a predisposing factor for acute glomerulonephritis--report of two cases

This is a review of two children who developed acute glomerulonephritis (AGN) following acute gangrenous appendicitis (AGA) with periappendicular collections. The first patient presented with AGN during the course of appendicitis. The second patient developed AGN after appendectomy. Both patients did not have any other predisposing factors. AGN resolved in both patients after massive intravenous antibiotics. This is the first report of acute appendicitis as a predisposing factor for AGN

Laparoscopic common duct exploration in a child with recurrent pancreatitis due to a primary fungus ball in the terminal common bile duct.

We report on a case of a fungus ball obstructing the distal common bile duct and causing recurrent pancreatitis in an otherwise healthy 3-year-old boy. Laparoscopic exploration of the common bile duct was performed using a 10 french rigid fiberoptic cystoscope and a Dormia basket. This is the first example of a primary fungus ball in common bile duct presenting as a pancreatitis and treated laparoscopically.

Femoral neuropathy secondary to the use of a self-retaining retractor. Report of three cases and review of the literature.

PURPOSE: Three recent cases of femoral neuropathy at our institution following colorectal surgery have been ascribed to the use of the self-retaining Bookwalter retractor. The pathophysiology of neural injury includes compression, stretch, transection, ligation, iliopsoas hematoma, ischemia, and cement encapsulation. The aim of this study is to provide a comprehensive review of femoral nerve anatomy and mechanism of retractor injury. METHODS: The relationship of the femoral nerve to the lateral blade of the Bookwalter retractor was evaluated during colorectal surgery and in cadaveric dissections. RESULTS: The lateral blade of the self-retaining retractor was observed to either compress or impinge the intrapelvic portion of the femoral nerve. CONCLUSION: The incidence of postoperative femoral neuropathy is likely underestimated because a majority of cases are self-limited. This debilitating iatrogenic injury can be prevented with a thorough understanding of femoral nerve anatomy and careful placement of self-retaining retractor blades.

Stapled stricturoplasty for Crohn's disease. A new technique.

PURPOSE: Stricturoplasty was originally used to treat multiple fibrotic strictures of tuberculosis. As the pendulum of treatment of Crohn's disease swung toward conservatism and bowel preservation, stricturoplasty was performed in Crohn's disease. Stricturoplasty can be used when there is limited, well-localized disease and should be avoided in the presence of grossly inflamed or infected material. We describe a new technique of stricturoplasty. METHODS: Typically stricturoplasty is performed in a manner similar to a Heineke-Mikulicz pyloroplasty. A stapled stricturoplasty technique has been previously described, but in actuality these are more similar to a bypass procedure. Our technique uses a stapled, open technique similar to the triangulating method of bowel anastomosis. This was performed in one patient to correct six strictures. RESULTS: Our patient did well postoperatively and developed no significant complications. He has no evidence of recurrent strictures. CONCLUSION: We describe a stapled stricturoplasty technique that is truly a stricturoplasty because the bowel lumen is increased; it is similar to the triangulating method of end-to-end stapled bowel anastomosis. It is safe, efficient, and effective. Additionally, it allows radiographic location of the stricturoplasty site, thus allowing determination of effectiveness of the procedure as well as recurrence.

Early postoperative feeding.

PURPOSE: Our intent was to show that immediate postoperative feeding of a regular diet after elective colorectal surgery was safe, tolerable, and feasible. METHODS: This was a nonrandomized, prospective study of 38 consecutive patients who underwent elective colorectal surgery over a three-month period. Our study parameters included operative length of time, intraoperative blood loss, need for transfusions, day to flatus or defecation, ability to tolerate a diet, placement of nasogastric tubes postoperatively, and length of hospital stay. These patients were compared with patients treated by different surgeons during the same time period but fed only after return of bowel sounds or flatus. RESULTS: Thirty-one of 36 patients eventually included in this study were able to tolerate our early feeding regimen. There were a total of seven other complications that were minor and unrelated to the early feeding. Patients who tolerated early feeding had shorter postoperative length of stays, 5.7 vs. 10.6 days. Patients who tolerated early feeding had shorter length of stays than patients treated in a more conventional manner, 5.7 vs. 8.0 days. Those who did not tolerate early feeding had longer procedures and greater intraoperative blood loss. CONCLUSIONS: Early postoperative feeding is safe and is tolerated by the majority of patients. Early feeding, if tolerated, decreases length of hospital stay and may decrease health care costs. Longer operative time and increased blood loss intraoperatively may indicate a more difficult procedure and identify those patients who will not tolerate early feeding.

Carotid bifurcationplasty: an alternative to patching.

Patching of carotid endarterectomies has been advocated as a means of both facilitating secure closure and minimizing recurrent stenosis. Most vascular surgeons occasionally, if not always, patch selected carotid arteries. However, patching requires the surgeon to utilize either prosthetic material (Dacron or PTFE), which is relatively thrombogenic, or autogenous vein, which requires a second operative field and available saphenous vein at the ankle. Bifurcationplasty, otherwise known as bifurcation advancement, has been used as an alternative to patching at our institution over the past four years. This technique, which involves the use of the opened, endarterectomized external carotid artery as an autogenous in-continuity patch for the internal carotid artery, obviates the need for prosthetic materials and saphenous vein alike. This procedure has been performed 30 times over a 4-year period (1987-91). During this time, 280 carotid endarterectomies were performed. A vein patch or Dacron was used in four cases early in this series. Bifurcationplasty was also the procedure of choice for repeat carotid endarterectomy, and was performed in five cases of recurrent stenosis after direct closure. In a follow-up period averaging 22 months (range 1-48), there were no instances of symptomatic restenosis. We feel that bifurcationplasty is an easily performed autogenous alternative to conventional patch closure of the carotid artery.

Cardiopulmonary bypass.

There has been a recent renewed interest in certain aspects of cardiopulmonary bypass employing extracorporeal circulation. Several areas have received special attention. Among these is the institution of extracorporeal circulation using a percutaneous technique for circulatory assistance during high-risk percutaneous transluminal coronary angioplasty. A national registry has been established to review and monitor results using this percutaneous technique. Several recent developments in the delivery of cardioplegia during ischemic arrest have stimulated investigative efforts. In particular, the delivery of cardioplegia in a retrograde manner through the coronary sinus has proved an effective and useful adjunct to myocardial protection during cardiopulmonary bypass with extracorporeal circulation. A newer investigative technique employing only warm cardioplegia delivered primarily through the retrograde coronary sinus route seems to offer some promise in providing optimal myocardial protection while minimizing hemorrhagic complications and other cold-induced myocardial injury. Because of concerns regarding blood transfusion-related communicable disease (eg, acquired immune deficiency syndrome and non-A, non-B hepatitis), there has been increasing research effort into postoperative hemorrhage related to cardiopulmonary bypass with extracorporeal circulation. Specifically, various drugs that may serve as hemostatic adjuncts have been investigated extensively. These drugs include aprotinin and desmopressin acetate. Likewise, several studies have evaluated other drugs (mainly aspirin) that have a negative influence on postoperative hemostasis. Additionally, there has been continued research interest in the activation of the inflammatory system during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS)