Surgical simulation of pediatric laparoscopic dismembered pyeloplasty: Reproducible high-fidelity animal-tissue model.

PURPOSE: To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of laparoscopic dismembered pyeloplasty in infants and children. MATERIALS AND METHODS: A previously described animal tissue model using chicken crop was surgically modified and attached to piglet kidney specimens in order to provide organ model realistically resembling infant and children hydronephrosis for simulation of dismembered laparoscopic pyeloplasty. Dismembered pyeloplasty could then be carried out in a standard pelvi-trainer using a standard instrumentation as in a regular case. RESULTS: The model created could prove to be a high-fidelity, animal tissue model for the surgical simulation of dismembered pyeloplasty. The surgical modification of the used animal tissues of chicken crop and piglet kidney respectively used in this fusion model was able to provide a high grade of resembling a realistic organ situs for infant and pediatric pyeloplasty, respectively. The surgical procedure could be carried out as a simulation of a regular case while providing high-grade realistic anatomy, adequate sizes of a dilated renal pelvis and of the ureter, respectively. Biological as well as haptic conditions of the tissue were able to resemble human tissue in a high grade as well. DISCUSSION: Despite a live animal model has been described for dismembered pyeloplasty, its time-consuming creation and possible conflict concerning animal welfare cadaver models are more practicable for daily simulation. In literature so far animal-tissue models described range from folded chicken skin to a chicken crop model. While these types of models have its own advantages and disadvantages none of them provide adequate anatomical relations. By dissecting chicken crop and fixating it to a piglet's kidney this limitation could be overcome and furthermore will enable future modifications for a perfused model for laparoscopic dismembered pyeloplasty. CONCLUSION: The fusion of a previously described tissue model of chicken crop for simulation of pyeloplasty along with also previously used piglet kidneys for surgical simulation can provide a highly realistic model for surgical simulation of pediatric dismembered laparoscopic pyeloplasty. In addition, this model rules out the disadvantage of native animal kidney specimens which the lack of pathology of a dilated renal pelvis. Surgical modification is an established method to provide high-fidelity animal tissue models for surgical simulation and therefore training of complex procedures, respectively. For simulation purposes in pediatric laparoscopic urology, i.e., reconstructive procedures such as dismembered pyeloplasty this model appears to be promising in terms of providing realistic pathology in pediatric dimensions.

Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles.

BACKGROUND: Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%. AIM: This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition. METHODS: Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015. RESULTS: A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended. DISCUSSION: The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies. CONCLUSION: The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.

"Resident as teacher" in pediatric surgery: Innovation is overdue in Central Europe.

PURPOSE: We set out to evaluate how residents in pediatric surgery learn and how they teach. We hypnotized that European residents learn as much from their peers and teach as much as their fellows worldwide, but that they receive comparably less educational training. METHODS: An online questionnaire was distributed to the participants of the combined annual meeting for German, Swiss and Austrian residents in pediatric surgery. Participants were asked whom they learn from in different workplace environments (ward, operating room, emergency department), how, when and why they adopt the role of teacher and how they were prepared for this role. RESULTS: Response rate was 48%. 65 questionnaires were analyzed. Residents stated that they predominantly learn from each other on wards and in the emergency department, less frequently in the operating room. They ranked fellow residents as first or second most important source of instruction. 53% of participants have never had any educational training, for another 33% the instruction was being done by fellow residents without any set curriculum. 93% of the participating residents had no or did not know about any resident as teacher training program available to them. Nevertheless, motivation to teach was stated to be high and interest in educational training was assured. CONCLUSIONS: Our data delivers evidence that peer teaching during residency is the rule rather than the exception in Central Europe. Educational training however is scarce. Resident as teacher-training programs need to be introduced. Next to local initiatives, we strongly recommend national initiatives powered by regulatory authorities and surgical associations. TYPE OF STUDY: Research paper. LEVEL OF EVIDENCE: II.

Nephron sparing surgery for synchronous bilateral nephroblastoma involving the renal hilus.

PURPOSE: Bilateral nephroblastoma involving the renal hilus represents a significant surgical challenge. Different operative strategies have been proposed for this condition. We analyzed the outcome of simultaneous bilateral partial nephrectomy for complex stage V nephroblastoma. MATERIALS AND METHODS: We retrospectively analyzed patients with bilateral nephroblastoma involving the renal hilus operated on at our institution between 2002 and 2008. We assessed patient data and surgical and oncologic outcomes. RESULTS: We analyzed data from 5 patients with a median age of 27 months at surgery (range 13 to 58). Two children had additional pulmonary metastases. Patients were treated according to the International Society of Pediatric Oncology 2001/German Society of Pediatric Oncology and Hematology protocol. All children underwent synchronous bilateral nephron sparing surgery (longitudinal partial nephrectomy or enucleation) of the central tumors. Median operating time was 182 minutes (range 129 to 291), with vascular exclusion performed in 4 patients (7 to 25 minutes). Complications consisted of urinary leakage in 2 cases. Postoperative renal function was unimpaired in 4 patients and 1 patient had Wilms tumor/aniridia/genitourinary malformations/retardation syndrome with glomerulopathy. One patient with pulmonary metastases and blastemal histology had multiple pulmonary relapses and died due to pulmonary progressive disease. Four patients are alive without evidence of disease at a median followup of 45 months (range 44 to 73). CONCLUSIONS: Surgery for central stage V nephroblastoma is possible with good functional and oncologic outcomes. The single stage approach is safe, provided that operating and treating physicians have sufficient expertise with such conditions. The ultimate goal is to avoid tumor nephrectomy.

Outcome of augmentation cystoplasty and bladder substitution in a pediatric age group.

OBJECTIVE: Aim of the study was to evaluate the outcome of augmentation cystoplasty and bladder substitution in a pediatric age group. METHODS: Patient records of all children who underwent reconstructive bladder surgery between October 1999 and November 2007 were reviewed. Additionally, standardized interviews were performed to evaluate the postoperative outcome. RESULTS: Augmentation cystoplasty and bladder substitution were performed in 19 and 6 patients, respectively. 21 patients underwent continent catheterizable vesicostomy. Postoperative urodynamics revealed a significant increase in bladder volume (median 400 ml) as well as a significant improvement in bladder compliance (median 13.5 ml/cmH2O). 90% of the patients were reported to be socially continent. Renal function remained stable in 95% and decreased in 5% of the children. Major complications were lower urinary tract calculi (39%), stricture or insufficiency of the continent vesicostomy (28%), and intestinal obstruction (9%). No malignancies associated to bladder augmentation or substitution were detected yet. CONCLUSION: Augmentation cystoplasty and bladder substitution preserve renal function and provide urinary continence in most children with intractable lower urinary tract disease. However, the procedures remain associated with numerous complications.

Laparoscopic surgery on upper urinary tract in children younger than 1 year: technical aspects and functional outcome.

PURPOSE: Minimally invasive procedures are increasingly important in pediatric urology. However, experience is still limited with minimally invasive operations on the upper urinary tract in infants. We analyzed 3 minimally invasive procedures (pyeloplasty, heminephroureterectomy and nephrectomy) in children younger than 1 year. MATERIALS AND METHODS: We analyzed 67 children (mean +/- SD age 5.1 +/- 2.9 months) undergoing minimally invasive pyeloplasty in 26 patients (group 1), heminephroureterectomy in 18 (group 2) or nephrectomy in 23 (group 3) with regard to technical aspects, surgical outcome and complications. Preoperative and postoperative ultrasound and mercaptoacetyltriglycine renal scan were statistically evaluated in groups 1 and 2. RESULTS: Mean +/- SD patient weight was 6.4 +/- 1.8 kg and mean +/- SD operative time was 113.2 +/- 41.6 minutes. Conversion to open surgery was necessary in 1 pyeloplasty. One complication (missed intraoperative bowel perforation) occurred. No blood transfusion was required in any child. After pyeloplasty there were improved tracer clearances (mercaptoacetyltriglycine scan) and improved morphologies of the pyelon (ultrasound) in all patients. In groups 1 and 2 there was no statistical difference between preoperative and postoperative partial function of the affected kidney. Mean +/- SD followup was 32.5 +/- 19.8 months. CONCLUSIONS: Minimally invasive procedures on the upper urinary tract in children younger than 1 year are technically challenging, and require expertise of the surgeon and the entire team. Given these assumptions, such procedures can be safely performed with excellent functional outcomes.

Outcome of transanal endorectal pull-through in patients with Hirschsprung's disease.

INTRODUCTION: Various outcomes following transanal endorectal pull-through (TERPT) in patients with Hirschsprung's disease (HD) have been reported. In this study, the postoperative course and functional outcome after TERPT in 25 patients with HD is evaluated. METHODS: Patient records of children who underwent TERPT for HD between 2002 and 2007 were reviewed retrospectively. Age at surgery, sex, associated malformations, length of follow-up, presence of colostomy, indication for laparotomy, length of the aganglionic segment, result of rectal examination under general anaesthesia 6 weeks after surgery, necessity of a dilatation program or reoperation were investigated. In addition, standardised interviews were performed to collect the following data: bowel movement per day, faecal continence in potty-trained children or in patients older than 3 years, incidence of diarrhoea or problems with micturition and the necessity for laxative therapy. RESULTS: Between 2002 and 2007, 25 patients underwent TERPT for HD. Median age at the time of surgery was 3.5 months. Median follow-up was 35 months. Calibration of the anus showed a normal age-related diameter of the anus in 12/20 children and a markedly reduced diameter in 8/20 children at 6 weeks postoperatively. Seven of the latter children underwent a dilatation program. A redo pull-through procedure was performed in 3 patients due to stenosis at the colo-anal anastomosis (n=1), a constricting muscle cuff (n=1) and a twisted pull-through (n=1). Two children developed enterocolitis. The median frequency of bowel movements was 3/day (1-5/day). Laxative treatment was required in only one patient (4.5%). None of the patients had diarrhoea. Nineteen children (86%) were potty-trained, being older than 3 years. Eighteen of them were continent (95%). One patient (5%) with trisomy 21 suffered from intermittent non-retentive faecal incontinence. None of the patients showed signs of neurogenic bladder dysfunction. CONCLUSION: The functional outcome in most patients after TERPT is satisfactory. We suggest that routine rectal digital examination and anal calibration under anaesthesia 6 weeks postoperatively might detect occult anodermal stenosis and allow early initiation of an anorectal dilatation program, which could decrease the incidence of enterocolitis, persistent constipation and the necessity for further surgical intervention.

Sepsis and lung abscess following malposition of an umbilical vein catheter in a neonate.

BACKGROUND: Umbilical vein catheterisation is a common and useful procedure in the care of critically ill newborns, but several complications may occur. PATIENTS: We report on a newborn, who developed sepsis and necrotizing pneumonia of the right middle lobe due to extended spectrum beta lactamase (ESBL) Klebsiella following malposition of an umbilical vein catheter into a right pulmonary vein. RESULTS: Due to failed conservative treatment the child required lobectomy of the right middle lobe. CONCLUSION: Our case highlights the importance of exact determination of the position of central catheters by x-ray and/or ultrasound immediately after placement.

[Thoracoscopic anatomical lung resection in children]. / Die thorakoskopische anatomiegerechte Lungenresektion im Kindesalter.

There are only few pediatric surgical centers across the world with expertise for minimally invasive anatomical lung resections in children. Between September 2003 and September 2005, 67 children underwent thoracoscopic surgery at the Department of Pediatric Surgery, University Hospital of Tuebingen, Germany. In 19 of these cases a lung resection was carried out, 8 of them had an anatomical lung resection. All patients underwent general anesthesia without selective intubation for the procedure. Intrathoracic pressure with insufflation of carbon dioxide of 1.5 l / min was held at 3-5 mmHg. Two 5 mm ports for video and instruments and one 12 mm port for a stapling device were used. Resected lung specimens were removed from the thorax through an additional 2-3 cm long incision. A bronchoscopy was carried out during surgery in all patients. Median age at operation was 5.6 years (range 3 months-20 years). Median operation time was 150 minutes (range 94-250 min). Conversion to open surgery was performed in 3 cases. This was due to bleeding in one child, due to a stiff lung in another patient with cystic fibrosis and due to a vascular and bronchial malformation in a third child suffering from middle lobe syndrome. There were no postoperative complications. Our preliminary results show, that thoracoscopic lung resections in children can be performed without major complications and excellent cosmetic results. For the necessity of a conversion to open surgery possible reasons may be insufficient intrathoracic overview as well as congenital anomalies of the vascular and / or the bronchial tract. Co-morbidities such as rib-fusion, deformities of the thorax or scoliosis can be avoided using thoracoscopic procedures.

The role of reovirus type 3 infection in an established murine model for biliary atresia.

AIM OF THE STUDY: Infection of newborn Balb/c-mice with Rhesus rotavirus (RRV) leads to cholestasis and biliary atresia. In this current model, Reovirus Type 3 was investigated to ascertain whether Reovirus Type 3 causes the same or similar hepatobiliary lesions as RRV. METHODS: Newborn Balb/c-mice were infected with Reovirus Type 3 Dearing and Reovirus Type 3 Abney on the first day of life. Clinical observation followed for a period of at least 10 days. Cholestatic and/or dystrophic mice were prepared and specimens were taken for histological examination. RESULTS: Infection with RRV showed a 85 % morbidity for biliary atresia as described before. Clinical disease, following an infection with Reovirus T3 Dearing, showed neurological symptoms such as ataxia, and all mice died within 3 weeks. No obstructive or atretic changes of the hepatobiliary ducts could be seen either macroscopically or histomorphologically. 60 % of the mice having been infected with Reovirus T3 Abney showed signs of cholestasis and oily fur syndrome, but almost 15 % recovered from the disease. Although the histological findings did not reveal biliary atresia, inflammation and destruction of bile ducts could be observed. CONCLUSION: In comparison to the RRV infection in a Balb/c-mice model, where biliary atresia could be induced, infection with Reovirus T3 in this model did not lead to biliary atresia. But Reovirus T3 Abney infection revealed inflammatory signs as described in the literature before. The question as to why different hepatotrophic viruses lead to different changes in the murine hepatobiliary tract has to be investigated in further studies.

Immunological gap in the infectious animal model for biliary atresia.

BACKGROUND: Extrahepatic biliary atresia (EHBA), the etiology of which still remains unclear, occurs exclusively in newborns and has recently been simulated in an animal model. It is possible to trigger an EHBA corresponding to the human disease by means of intraperitoneal infection of newborn Balb/c mice with rhesus rotavirus (RRV). The aim of the present study was to determine the conditions and circumstances for inducing biliary atresia in this model focusing on first-line immunological aspects. METHODS: Newborn as well as pregnant Balb/c mice were intraperitoneally infected with RRV. RESULTS: The highest incidence of cholestasis (86%) was achieved by infection with 10(6) PFU/ml RRV within the first 12 h postpartum, resulting in EHBA with a lethality of 100%. However, the later the newborn mouse is infected, the less likelihood there is that EHBA is triggered. Additionally, the incidence of biliary atresia in this model depends on the quantity of the virus that is given intraperitoneally. However, the development of biliary atresia is not correlated to the virus in the liver. The antepartum infection of pregnant mice does not induce EHBA in the offspring. Female mice that are immunized against RRV protect their newborns from developing RRV-induced cholestasis and EHBA. This protection is transmitted transplacentally and not by breast milk. CONCLUSION: It is obvious that a temporary immunological gap is essential for virally induced EHBA. Further studies should focus on specific parameters of the immune system of newborn mice in this biliary atresia model.

Effective treatment of infantile choriocarcinoma in the liver with chemotherapy and surgical resection: a case report.

Infantile choriocarcinoma of the liver is an extremely rare entity, and outcome has been fatal in almost all published cases. To the authors' knowledge, this is the first report on successful treatment with preoperative chemotherapy. A 10-week-old girl presented with a large liver tumor, ovarian cysts, cardiac insufficiency, progressive hemolytic anemia, and thrombocytopenia. Ultrasound scan and magnetic resonance tomography (MRT) showed the typical pattern of infantile hemangioendothelioma. An emergency laparotomy was performed because of increasing cardiac insufficiency with ligation of the right hepatic artery, tumor biopsy, and subtotal resection of the ovarian cysts. Histology findings showed a choriocarcinoma of the liver and corpus luteum cysts of the ovaries. Serum beta-human chorionic gonadotropin (beta-HCG) was elevated to 1.600.00 U/L. Chemotherapy was initiated with etoposide and cisplatin. When x-ray examination showed development of lung metastases, chemotherapy was intensified with etoposide, cisplatin, and ifosfamid according to the German Study Group of Extracranial Nontesticular Malignant Germ Cell Tumors in Childhood and Adolescence (MAKEI-96). Serum beta-HCG levels decreased further, ultrasound examination showed significant tumor reduction, and pulmonal metastasis could no longer be found in chest x-rays. After the fourth course, a complete tumor resection was achieved by an extended right hemihepatectomy with adjuvant chemotherapy being administered after the operation. The child has been in complete remission for 22 months. The authors' experience shows that chemotherapy is effective for preoperative tumor reduction.

[Complications in children with ulcerative colitis after total colectomy and J-pouch]. / Komplikationen bei Kindern mit Colitis ulcerosa nach totaler Kolektomie und J-Pouch-Anlage.

Our experience with proctocolectomy and the J-pouch procedure in eight children with ulcerative colitis is reported. The mean age at diagnosis was 8.4 years, and the mean time between diagnosis and colectomy was 2.2 years. We decided on a three-stage operation. The protective ileostomy was removed after approximately 4 months pouch-training. Two patients suffered pouchitis as a specific complication. An ileus occurred in two patients, one patient had a serious eosinophilic enteritis, and two children had multiple abdominal wall abscesses. All patients showed a significant increase in height velocity and the prepubertal patients experienced catch-up growth after the colectomy. All patients are continent during the day. Our experience suggests that proctocolectomy and the ileoanal-J-pouch procedure provide improved growth, continence and a low incidence of surgical complications.

[Surgical treatment of chronic pancreatitis in children]. / Operative Behandlung der chronischen Pankreatitis bei Kindern.

Chronic relapsing pancreatitis and its hereditary form are very rare in children. Our experience with early operative treatment in nine children is presented. The good exocrine and endocrine function of the pancreas in these patients justifies early operation when typical changes of the pancreatic duct are present since it shortens the relapsing clinical course and maintains good function of the pancreas.

Value of a score in the electromanometrical diagnosis of neuronal intestinal dysplasia.

Anorectal manometry was performed in a series of 8 children where NID was histochemically confirmed or suspected. The results were transferred to a electromanometric score theoretically worked out previously. Clinical symptoms as well as histological and manometric findings have been compared concerning the meaningfulness of the electromanometric score in the diagnosis of NID. It was impossible to make a statistical statement due to the small number of patients we examined. It seems, however, that certain electromanometric parameters in NID appear regularly which, when combined in a score, make manometric diagnosis of NID sufficiently reliable.