Delayed Cholecystectomy Management for Mirizzi Syndrome.

Mirizzi syndrome is defined as a common hepatic duct obstruction from a cystic duct stone, which results in a severe inflammatory reaction that distorts biliary anatomy and makes surgical intervention challenging. Most case reports describe an open subtotal cholecystectomy as the most common surgical technique with few reports detailing successful laparoscopic interventions. This case involves an 11-year-old African American female who presented with right upper quadrant abdominal pain and imaging consistent with Mirizzi syndrome. She was taken for a laparoscopic cholecystectomy that was quickly aborted due to extensive inflammation. She subsequently underwent endoscopic decompression of her biliary tree by gastroenterology. She returned to the operating room six weeks later for a successful interval cholecystectomy. This case illustrates a unique report of delayed cholecystectomy for management of Mirizzi syndrome, which highlights a potential management strategy that avoids technically difficult laparoscopic cholecystectomy in the acute inflammatory period.

Laparoscopic versus open reduction of intussusception in children: experience over a decade.

BACKGROUND: Intussusception is a common cause of bowel obstruction in children, which sometimes necessitates operative reduction and or resection. We report our series of patients with intussusception who were treated laparoscopically (LAP group) compared with exploratory laparotomy (OPEN group). SUBJECTS AND METHODS: After institutional review board approval, a retrospective review was performed evaluating outcomes for patients requiring surgical reduction of intussusception over a 10-year period. Analysis was based on intent to treat, and technique of exploration was surgeon's choice. Data were analyzed with the Wilcoxon rank sum test and chi-squared test where appropriate. P≤.05 was considered significant. RESULTS: During the time period studied, there were 92 patients treated surgically for intussusception: 65 LAP and 27 OPEN. Conversion to the open procedure was required for 21 patients in the LAP group, and of those, 6 required bowel resection. Seven of the patients who were started in the OPEN group ultimately required bowel resection. Operative time, length of hospital stay, time to full feeds, and total days of narcotics were all significantly shorter for the LAP group compared with the OPEN group (P=.003, P=.001, P=.001, and P=.004, respectively). A pathologic lead point was found in 14% of LAP and 15% of OPEN cases. In a subset analysis, 33% of patients who were converted from the LAP group to the open procedure had a pathologic lead point. Complication rates between the LAP and OPEN groups were comparable. CONCLUSIONS: Laparoscopy appears to be a safe and effective technique for reducing intussusception in children. The laparoscopic cases had shorter operative time, shorter time to full feeds, lower requirement for intravenous narcotics, and earlier discharges.

Laparoscopic versus open repair of congenital duodenal obstruction in infants.

BACKGROUND/PURPOSE: Congenital duodenal obstruction (CDO) is traditionally managed via laparotomy. Laparoscopy has been suggested as an alternative; however, few series have described this in neonatal CDO. We report our series of CDO repaired laparoscopically compared to laparotomy. METHODS: After Institutional Review Board approval, a retrospective review was performed on patients with CDO who were presented between October 2001 and July 2010. Duodenal obstruction was managed laparoscopically (LAP) or via an open approach (OPEN) based on the surgeon's choice. Data were analyzed by intention to treat and were expressed as median±range. RESULTS: Twenty-two neonates underwent laparoscopy and 36 had a traditional laparotomy for management of CDO. Associated diseases included Down's syndrome (n=26), congenital heart disease (n=29), and malrotation (n=16). Median age was 4 days (range: 1-310) for LAP and 3 days (range: 0-166) for OPEN (P=.04). Gestational age and weight were similar (P=.335 and .378). The CDO was due to atresia (n=32), web (n=16), and annular pancreas (n=10). Median operative time for LAP was 116 minutes with a range of 73-164 while median time for OPEN was 103 minutes with a range of 71-220 (P=.013). There was no difference in time to full feedings (P=.69) or postoperative length of stay (P=.682). Ventilation time was 2 days with a range of 0-149 for LAP and ventilation time was 4 days with a range of 0-9 for OPEN (P=.02). Complication rates between the groups were similar. CONCLUSION: In the hands of a skilled surgeon, laparoscopy appears to be a safe and effective technique in managing CDO in neonates. In this retrospective study, laparoscopic management of CDO appeared to allow a shorter postoperative ventilator requirement with similar length of stay and time to full feedings. Operative time was slightly longer in the LAP group. Formal prospective trials are recommended to validate these findings.

Retropleural teratoma presenting as an abdominal mass in a 9-month-old boy.

BACKGROUND: Teratomas are rare tumors that present most commonly in the anterior mediastinum and retroperitoneum. To date, the retropleural primary site has not been reported. CASE PRESENTATION: A 9-month-old boy presented with a large, painless, right-sided abdominal mass. Laboratory values, including tumor markers α-fetoprotein and ß-human chorionic gonadotropin, were within normal limits. Diagnostic imaging, including abdominal ultrasound, computed tomographic scan, and magnetic resonance imaging, suggested a large retroperitoneal mass consistent with a teratoma. Because the mass was thought to be arising from the retroperitoneum, an abdominal approach was chosen. After adequate exposure, it became clear that the tumor was arising from above the diaphragm. The diaphragm was incised, and the pleural cavity was entered. The tumor was found in the retropleural space where it was dissected away from the inferior vena cava, aorta, and chest wall. The patient recovered without complications. RESULTS: Histologic examination revealed a mature cystic teratoma with no malignant features. The patient has been disease-free at 7-year follow-up, based upon both clinical examination and diagnostic imaging. CONCLUSION: This is the first case report of a teratoma arising from the retropleural space. Preoperative imaging may be inaccurate for guiding surgical planning because the diaphragm may not be clearly visualized with current diagnostic techniques. Surgeons should be cautious regarding the location of tumors that arise near the diaphragm and should plan surgical resection carefully.

Role of hepatic portocholecystostomy ('gallbladder Kasai') in treating infants with biliary atresia.

The aim of this study is to compare liver function and cholangitis episodes during the first year postoperatively between patients who undergo hepatic portocholecystostomy (HPC) and patients who undergo hepatic portoenterostomy (HPE). Records of six patients who underwent HPC for biliary atresia (BA) and 27 patients who underwent HPE for BA were reviewed retrospectively. Comparison was done of the patient's total bilirubin, albumin, and international normalized ratio values preoperatively and at 3 months, 6 months, and 1 year postoperatively. Comparison was also done of the occurrence of ascending cholangitis during the first year postoperatively and in rates of transplant and mortality during long-term follow-up. Preoperative laboratory values between the two groups were not significantly different. At 6 months, the patients who underwent HPC had significantly lower total bilirubin levels compared with those who underwent HPE (HPC 0.8 +/- 0.96, n = 4; HPE 4.93 +/- 7.73, n = 21; P < 0.05). No other laboratory values or rates of ascending cholangitis, transplant, or mortality showed a significant difference. Those patients who underwent HPC had significantly lower total bilirubin levels at 6 months postoperatively. This may suggest that HPC may be a superior operative technique for patients who are candidates for the operation.

Minimally invasive thoracoscopic ultrasound for localization of pulmonary nodules in children.

PURPOSE: Children with cancer may develop lesions in the lung that may represent metastatic disease. Thoracotomy is considered the standard approach for resection of pulmonary nodules. Recently, thoracoscopic techniques have been applied in these situations. However, nodules that are deep in the lung parenchyma may not be visible. A technique has been developed whereby minimally invasive thoracoscopic ultrasound (MITUS) may be used to guide resection of deep pulmonary nodules. METHODS: We conducted a retrospective review of children undergoing MITUS at our institution. Only patients with single isolated lesions were chosen to have this diagnostic procedure performed. Patients undergo single lung ventilation. Two 5-mm ports are inserted, one for the grasper and the other for the camera. One 12-mm port is inserted for the flexible 10-mm ultrasound probe and the endoscopic stapler. The patient has CO(2) insufflation to create a 5-mm Hg pneumothorax. Twenty mL/kg of normal saline is introduced into the chest cavity for acoustic coupling. The ultrasound probe is used to isolate the nodule(s), guide resection, and check margins. The specimen is removed and placed in a removable specimen bag to reduce the chance of port site recurrence. After the lung has been inspected, irrigation is removed, and a chest tube inserted. RESULTS: Eight procedures were performed on 7 patients (5 males, 2 females) with a median age of 15.2 years (range, 4-18 years). Patients had primary diagnoses of osteosarcoma (n = 4), Wilms' (n = 2), and lymphoma (n = 1). The median size of the lesions that were being isolated was 0.6 cm (range, 0.3-2.9 cm). None of the nodules removed were visible on the surface of the lung. Of the 8 procedures, 7 led to the removal of a pulmonary nodule. Of the 7 nodules isolated, 5 were removed thoracoscopically, with two requiring minithoracotomy because of anatomical limitations. The histologic evaluation on these specimens included osteosarcoma (n = 4), abscesses (n = 2), fibrosis (n = 1), and lymph node (n = 1). The median hospitalization was 2.5 days (range, 2-39 days). One patient had a prolonged hospitalization because of air leak and sepsis. CONCLUSION: Minimally invasive thoracoscopic ultrasound is a real time imaging tool that helps isolate small pulmonary lesions that may otherwise be difficult to see intraoperatively. We would advocate this technique for those patients having video-assisted thoracoscopy to assist clarifying whether focal lesions are malignant, thereby guiding therapy.

Video-assisted transumbilical Meckel's diverticulectomy in children.

The treatment of Meckel's diverticulum (MD) in children is resection. Some data exist for the use of laparoscopic resection. The Video-Assisted Transumbilical (VAT) single-trocar technique has been recently described for appendectomy. We also have used this technique for the resection of MD. The purpose of this study is to report our experience with laparoscopic-assisted resection of MD using both the three-trocar and the single-trocar techniques. The Institutional Review Board approved our retrospective chart review of all patients with the diagnosis of MD. Only the cases that were treated via laparoscopy were included. Technique of resection was at the discretion of the surgeon. Nine patients underwent laparoscopic resection of an MD from 2000 to 2005. Four patients underwent the three-trocar technique (LAP n = 4) and the remaining five underwent the video-assisted transumbilical single-trocar technique (VAT n = 5) procedure. Indications for surgery included gastrointestinal bleeding (VAT n = 3; LAP n = 2), malrotation (LAP n = 2), intussusception (VAT n = 1), and abdominal pain (VAT n = 1). All patients were male, and ages ranged from 7 months to 17 years for the VAT group and 8 months to 15 years for the LAP group. The average length of surgery for the LAP versus VAT was 128 minutes (94-170 minutes) and 81.4 minutes (42-96 minutes) respectively. Of the five patients undergoing LAP, two Ladd's procedures and three appendectomies were included during the same anesthesia. Only a single appendectomy procedure was performed during a VAT. The average time until full feeds with the LAP and VAT was 4.3 days (2-8 days) and 2.0 days (1-3 days) respectively. The overall length of stay with LAP versus VAT was 4.3 days (2-8 days) and 3.7 days (2-5 days). Only one case using the LAP method required conversion to an open laparotomy. Though no randomized trial for the removal of MD exists, our data suggest that the use of laparoscopy for removal of both symptomatic and asymptomatic MD is safe and effective. Additionally, the one trocar technique is feasible and may be beneficial in terms of fewer incisions and operative costs; however, more patients need to be studied.

Glucocorticoid rescue for late-phase acute respiratory distress syndrome in trauma/surgical critical care patients.

High-dose glucocorticoid therapy (GCT) for the late fibroproliferative phase of acute respiratory distress syndrome (ARDS) is controversial and has shown mixed results in medical patients. No studies have evaluated GCT in trauma/surgical critical care patients. The purpose of this study is to review the outcomes of trauma/surgical critical care patients with refractory ARDS treated with GCT. From January 2001 through September 2005, a pharmacy log was used to identify critically ill trauma/surgical patients in refractory ARDS (7 males and 2 females) who received GCT in an attempt to salvage them. GCT consisted of 200 mg intravenous methylprednisolone bolus for one dose and then 3 mg/kg per day divided every 6 hours for 6 weeks or until weaned off the ventilator. All patients as well as the survivors were analyzed. Outcome data was analyzed with SPSS (Chicago, IL) and the paired sample test. A P value < or = 0.05 was considered significant. Data is presented as mean +/- standard deviation. The Institutional Review Board approved this retrospective chart review. Seven patients (6 males and 1 female; age, 31 +/- 16 years) survived (78%), weaned off of the ventilator, and were discharged from the hospital. The 2 deaths were secondary to refractory respiratory failure as well as cardiac arrest (n = 1) and anoxic brain injury from septic hypotension (n = 1). In survivors (n = 7), hospital length of stay (LOS) and intensive care unit LOS was 71 +/- 30 days and 53 +/- 16 days, respectively. Duration of GCT administration was 17 +/- 6.4 days (range, 11-30 days). Ventilator time before GCT, during GCT, and after GCT was 22 +/- 8.4, 15 +/- 7.5, and 1.6 +/- 6.0 days, respectively. During GCT, 8 patients developed pneumonia, 5 had urinary tract infection, and 3 had bacteremia. All infections were effectively treated with broad-spectrum antibiotics, except in one patient who died of sepsis. PaO2/FIO2 ratio just before and after GCT was 100 +/- 36 and 247 +/- 56, respectively (n = 7; P < 0.001). Sequential organ failure assessment score just before and after GCT was 9.1 +/- 2.3 and 5.0 +/- 1.6, respectively (n = 7; P < 0.001). GCT rescue may have a role in salvaging critically ill trauma/surgical critical care patients in late-stage ARDS. More patients, however, need to be studied.

Video-assisted transumbilical appendectomy in children.

BACKGROUND: Video-assisted transumbilical appendectomy (VATA) is a combination of laparoscopic and open techniques and is not widely used in children. We are reporting our most recent experience with this technique. METHODS: After the institutional review board approval, the charts of patients who underwent VATA between December 2003 and October 2004 were retrospectively reviewed. All children presenting with a preoperative diagnosis of appendicitis were candidates. A 10-mm trocar was placed in the umbilicus. An operating laparoscope was used for mobilizing the appendix. The appendix was delivered through the umbilicus. A standard extracorporeal appendectomy was performed. The umbilical ring was closed and the wound irrigated. Demographic and outcome data were collected and is presented as mean +/- SD. RESULTS: Sixty-one males and 50 females underwent VATA (n = 111). Age and weight were 11 +/- 3.2 years and 49 +/- 22 kg, respectively. Six patients had previous abdominal surgery. Operative time was 36 +/- 24 minutes (range, 9-140 minutes). An additional trocar was placed in 2 patients, and 2 patients were converted to open. Five patients had additional procedures. Appendicitis was classified intraoperatively as acute (n = 44), suppurative (n = 5), gangrenous (n = 8), ruptured (n = 30), appendiceal colic (n = 13), and other (n = 11). Preoperative antibiotics were given to 95 patients and were continued in 35 patients postoperatively. Length of stay was 1.8 +/- 1.7 days (range, 1-11 days). Length of follow-up was 13 +/- 6.3 days (n = 90). Complications included intra-abdominal abscess (n = 1) and wound infection (n = 7). CONCLUSIONS: Video-assisted transumbilical appendectomy minimizes equipment needs, thus, potentially reducing cost. Simple and complex appendectomies can be performed even if the patient has had previous abdominal surgery. Our complication rate was low, and our operating times and length of stay were short. Video-assisted transumbilical appendectomy is a safe and effective technique in children and can be used in lieu of the 3-trocar laparoscopic technique.

Video-assisted thoracoscopic surgical excision of cystic lung disease in children.

PURPOSE: Video-assisted thoracoscopic surgical (VATS) technique for resection of cystic lung disease (CLD) may offer some advantages when compared with thoracotomy in children. METHODS: From September 1999 to August 2004, 6 pediatric patients underwent VATS for CLD. Patients were chosen for VATS based upon surgeon's choice. Data are expressed as mean +/- SD. The Children's Healthcare of Atlanta institutional review board approved this study. RESULTS: The types of lesions included congenital cystic adenomatoid malformations (n = 1), extrapulmonary sequestrations (n = 3), congenital lobar emphysema (n = 1), and bronchogenic cyst (n = 1). The extent of resection included lobectomy (n = 2) and excision (n = 4). Age and weight were 11.8 +/- 18 months (range 6 days to 4 years) and 7.5 +/- 3.6 (range 4.0-14.0) kg, respectively. Operating time was 103 +/- 70 (range 38-223) minutes. Chest tube duration was 1.2 +/- 0.8 (range 0-2) days. Morphine use on the first postoperative day was 0.2 +/- 0.3(range 0.05-0.20) mg/kg. Length of stay was 2.5 +/- 1.9 (range 1-6) days. There were no conversions to thoracotomy and no complications. CONCLUSION: VATS technique appears to be a safe and effective technique in managing CLD in children of all ages. More patients, however, need to be studied.

Video-assisted thoracoscopic division of vascular rings in pediatric patients.

Vascular rings are usually repaired via left thoracotomy. We report our series of pediatric patients with vascular rings that were repaired thoracoscopically. From February 2002 to September 2004, 13 patients underwent video-assisted thoracoscopic surgical techniques (VATS) division of their vascular ring. Chest magnetic resonance arterography (MRA) and/or computed tomographic arteriography (CTA) were used to evaluate the vascular ring in most patients. Patients were chosen for VATS repair based on surgeon's choice and type of vascular ring. Data are expressed as mean +/- SD. The Children's Healthcare of Atlanta Institutional Review Board approved this retrospective chart review. Age and weight was 1.5 +/- 1.8 years (range: 4 months - 17 years) and 16.0 +/- 12.5 kg (range: 6.0 - 22.1 kg), respectively (n = 13). Associated diseases included congenital heart disease (n = 2). Symptoms included respiratory complaints (n = 6), dysphagia (n = 2), dysphagia and shortness of breath (n = 1), pneumonia (n = 2), tracheal deviation (n = 1), and one patient was asymptomatic. Vascular ring types included double aortic arch (n = 4) and right aortic arch with an aberrant left subclavian artery and a left ligamentum arteriosum (n = 9). Operating time was 70 +/- 20 minutes (range: 46 - 122 minutes). One patient had to be opened because of a large arch. Length of stay was 1.9 +/- 0.9 days (range: 1 - 3 days). There were no complications, and all patients improved clinically at follow-up. Thoracoscopic repair of certain types of vascular rings seems to be safe and effective in children. More patients, however, need to be studied.