Endoscopic hyaluronic acid/dextranomer gel implantation is effective as first-line treatment of vesicoureteral reflux (VUR) in children: a single centre experience.

PURPOSE: Aim of the study was to analyse the success rate of endoscopic treatment (ET) using Dx/HA for primary vesicoureteral reflux (VUR) in children and to assess the incidence of postoperative urinary tract infections (UTIs). METHODS: We retrospectively reviewed the charts of 103 children with VUR grade II-V who underwent ET, including children with additional urogenital malformations. Outcomes were verified with voiding cystourethrography (VCUG) and periodical urinalysis. RESULTS: 103 children with a total of 174 ureters underwent ET. 71 patients presented with bilateral VUR. Additional malformations were: duplex ureters (19 patients), posterior urethral valves (PUV) (12 patients), diverticulum (4 patients), neurogenic bladder and ectopic orifice. VUR grade was II in 52, III in 74, IV in 41 and V in 7 ureters, respectively. Postoperative VCUG demonstrated no VUR in 140 ureters (80%) and diminished VUR grade in an additional 18 ureters (total 91%). After a second ET, VCUG was negative in 28 ureters. The overall success rate was 98%. 30 patients had had more than 3 febrile and 67 patients had had 1-3 febrile UTIs before ET. 4 out of 103 patients (3.9%) had 1 febrile UTI within the first year of follow-up. Serious complications after ET were not noted. CONCLUSION: ET is effective at eliminating VUR in children, even in patients with high-grade reflux, as well as in patients with VUR and additional malformations. Early intervention may reduce the incidence of UTIs and prevent long-term renal damage.

[Laparoscopic "single-port" appendectomy in children]. / Laparoskopische "Single Port"-Appendektomie im Kindesalter.

BACKGROUND: In contrast to the laparoscopic three trocar-technique and to the single incision laparoscopic surgery (SILS), the "single-port" appendectomy (SPA) requires only one port with one integrated instrument channel. We report on our experience with this half-open surgical technique. PATIENTS / MATERIALS AND METHODS: Between September 2006 and August 2008 a total of 285 children underwent an appendectomy, 265 in SPA technique. Through a 10 mm subumbilical inserted ballon trocar, diagnostic laparoscopy was routinely performed and, afterwards, the appendix was grasped with a 450 mm forceps, exteriorised and dissected outside the abdomen as in open surgery. Patients with perforated appendicitis detected by preoperative ultrasonography were operated by open appendectomy. RESULTS: 94 % of the SPA were performed successfully with no conversion. In six patients (2.3 %), a second trocar was inserted, in seven children (2.6 %), an extension of the incision became necessary. There were three conversions (1.1 %) to open surgery. The median operating time was 50 min and the median length of hospital stay 4 days. Three children had postoperative wound infections (1.1 %). CONCLUSIONS: SPA is a safe alternative to conventional appendectomy techniques, in part also in cases of perforated appendicitis. The minimal scarring guarantees an attractive cosmetic result. The diagnostic laparoscopy enables one to obtain additional information. In the case of extended adhesions, an extension of the incision and / or the use of a second trocar may be helpful.

Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option.

INTRODUCTION: Despite the increasing use of flexible intramedullary nailing for the treatment of femoral shaft fractures during growth, the use of acute or delayed plaster fixation is still a widely practised alternative in preschool children. The purpose of this retrospective study was to analyse outcome following acute casting in preschool children with a focus on acceptable initial leg length discrepancy and angulation. MATERIAL AND METHODS: A retrospective study was performed of 46 children with femoral shaft fractures treated conservatively. It was possible to verify the outcome in 22 children with an average follow-up time of 7.5 years. We compared initial shortening and mal-angulation to radiographic data at the time of consolidation and clinical outcome. RESULTS: Most children sustained their fracture by falling out of bed or from their parent's arm. A hip spica including the foot of the injured side, a pelvic ring and the thigh of the uninjured leg was applied under sedation and manual traction. Mean time of hospital stay was 1.4 days (range, 2 h-20 days). The average immobilisation time was 16.7 days (range, 0-30 days). At follow-up, on average 7.5 years after trauma, only one patient showed a leg length discrepancy greater than 2 cm. One patient showed a minor valgus and rotational deformity. CONCLUSION: The long-term outcome for conservatively treated femoral shaft fractures in preschool children is very good, even in severely dislocated fractures. Our data show that even initial shortening of up to 2.5 cm can be treated successfully with a spica cast.

Improvement of renal split function in hydronephrosis with less than 10 % function.

PURPOSE: The split function (SF) of hydronephrotic kidneys may dramatically decrease in the presence of severe and persistent obstruction, necessitating surgical correction. The indication for pyeloplasty versus nephrectomy is mainly based on the results of repeated renal ultrasonography (US) and MAG3-diuretic nephrography (DNG) with SF. Nephrectomy is usually recommended if SF is less than 10 %. However, recent studies with long-term follow-up indicate that even with an initial SF of < 10 %, a significant improvement of SF may be seen when pyeloplasty is performed so that nephrectomy may not be justified. PATIENTS AND METHODS: Case histories of 32 children with pre- or postnatally diagnosed severe hydronephrosis were retrospectively analyzed. Surgical correction was indicated if US revealed progredient hydronephrosis (anteroposterior diameter > 20 mm) and/or DNG demonstrated a loss of SF < 40 % and/or severe obstruction, respectively. Postoperative follow-up examinations included renal US after 3, 6 and 12 months, as well as DNG after 12 months. RESULTS: Thirty-two children (25 male, 7 female) underwent Anderson-Hynes pyeloplasty (AHP). At the time of operation, the mean age of the patients was 33 months (1 - 156 months). Patients were divided into 3 groups according to the initial SF: group I, 21 patients with SF > 40 %; group II, 7 patients with moderately impaired SF between 10 - 40 %; group III, 4 patients (aged 1 - 137 months) with a SF of < 10 %. In 2 patients, percutaneous nephrostomy (PCN) was performed, followed by AHP. Thirty patients underwent AHP without preceding PCN. In group III, SF increased from < 10 % preoperatively to 21 %, 27 %, 45 %, and 53 % postoperatively, respectively. In all patients, postoperative DNG demonstrated a significant improvement of SF from 41 %, on average, preoperatively (range 0 - 64 %) to 47 %, on average, postoperatively (range 17 - 60 %). CONCLUSION: Long-term follow-up confirms that the prognosis for renal function is excellent in patients with moderately reduced SF. The significant improvement of SF 12 months after AHP in all patients with a poor SF of less than 10 % supports our approach of performing pyeloplasty in patients even with an initial SF of < 10 %, which is in contrast to common practice.

Pulmonary function following completion of Minimally Invasive Repair for Pectus Excavatum (MIRPE).

UNLABELLED: Pulmonary function testing remains part of the routine preoperative investigations in patients with pectus excavatum, although there is evidence that reduced exercise capacity is predominantly due to impaired cardiovascular performance rather than ventilatory limitation. AIM OF THE STUDY: To evaluate the change of pulmonary function in patients after completion (metal bar removal) of minimally invasive repair for pectus excavatum compared to the preoperative functional results. PATIENTS AND METHODS: All patients who underwent minimally invasive repair for pectus excavatum (MIRPE) between February 2000 and June 2006 and subsequently had their metal bars removed were examined. Pulmonary function tests were performed as part of the routine pre- and postoperative protocol. Vital capacity (VC), forced expiratory volume in one second (FEV1), total lung capacity (TLC), residual volume (RV) and maximal expiratory flow rate at 25 % (MEF25) were evaluated. In addition, comparisons were made between patients with a low ( 6) pectus severity index (PSI) to establish the relative pre- to postoperative change of the above-mentioned lung function parameters. RESULTS: Fifteen patients were included in the study (14 males, 1 female). The median age at surgery was 15.9 years. The metal bar(s) were removed after a median of 37 months following the initial operation. Lung function tests were performed at a median of 32 days preoperatively and 129 days after completion of the procedure. Preoperative lung function values lay below population averages. The majority of patients had either a restrictive, obstructive or combined pulmonary disorder. Improvement was observed in all lung function parameters after metal bar removal compared to preoperative values and was significant for VC, FEV1 and the RV/TLC ratios. With regard to the severity of the deformity, although not statistically significant, patients with a higher PSI (> 6) appeared to benefit particularly from the operation. CONCLUSION: Our findings indicate that pulmonary function improves in patients after completion of minimally invasive repair of pectus excavatum. However, a review of the literature suggests that, in all probability, following surgery, patients benefit more with regard to enhanced cardiovascular performance than from improved pulmonary limitations. The value of routine testing of pre- and postoperative lung function in patients with pectus excavatum is questionable.

The relevance of surgical therapy for bilateral and/or multiple pulmonary metastases in children.

PURPOSE: Pulmonary surgery is frequently used for the treatment of metastases in children with various malignant diseases. The benefit of an aggressive surgical treatment in children with bilateral and/or multiple pulmonary metastases is still discussed controversially. METHODS: A retrospective analysis of 10 children (7 girls, 3 boys; age range from 2 to 16.5 years) who underwent thoracotomy for bilateral and/or multiple pulmonary metastases was performed. The primary malignancies were osteosarcoma (n = 4), hepatoblastoma (n = 3), malignant peripheral nerve sheath tumor (n = 1), adrenocortical carcinoma (n = 1) and alveolar rhabdomyosarcoma (n = 1). Unilateral but multiple pulmonary metastases were found in 3 children. 7 patients showed bilateral pulmonary metastases. Preoperative induction chemotherapy with tumor regression and a subsequent decrease in the size and number of pulmonary metastases was mandatory for the surgery of metastases. RESULTS: Standardized bilateral thoracotomy was performed in 4 patients in 1 operation (in 1 patient combined with a hemihepatectomy), and in 3 patients, in 2 operations on different days. 5 children underwent re-thoracotomy due to recurrent pulmonary metastases (2 patients: unilateral; 3 patients: bilateral; 1 patient: twice bilateral). All visible and palpable metastases (1 - 25) were excised, either by wedge resection, by segment resection or by lobectomy. Postoperative artificial ventilation was necessary for 0 to 24 hours. Postoperative complications included intrathoracic secondary hemorrhage in 3 cases and pneumonia in 1 patient. 2 patients (20%) died of recurrent metastatic disease (osteosarcoma: 1; adrenocortical carcinoma: 1). During a mean follow-up period of 49 months (14 to 66 months after the last thoracotomy), 8 patients (80%) remained in complete remission without clinically relevant respiratory restrictions. CONCLUSION: Complete surgical resection of pulmonary metastases after response to induction chemotherapy may increase survival in carefully selected children, even in cases with multiple and recurrent metastatic disease. In children, bilateral thoracotomy within a single operation is possible without an increased complication rate.

[Endosonographic determination of the volume of anal sphincter muscles as a parameter for continence outcome in childhood]. / Endosonographisch bestimmtes Volumen der analen Kontinenzmuskulatur als Parameter für die Kontinenzleistung im Kindesalter.

The volumes of the external and internal anal-sphincter muscles, determined by three-dimensional (3d) endosonography, are linear to each other and to the body-height and body-surface ratios in normal children. In patients with an operation of the sphincter muscles, the reduced volume of the external sphincter system permits a differentiation of incontinent children; the volume of the internal sphincter muscles, however, doesn't give a significant difference nor does the muscle-thickness. An acceptable estimation of the sphincter muscles volume can be made with conventional endosonography by planimetry of the muscle tissue in four representative axial cut-planes and by measuring of the sphincter-length.

[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.