Sociodemographics and the impact of a colostomy to indigent families and children with colorectal disorders in Honduras.

INTRODUCTION: To describe the social impact of a colostomy on indigent families and affected children with anorectal malformations (ARM) or Hirschsprung's disease (HD) in San Pedro Sula, Honduras, we specifically targeted very low-income households that attended an international medical brigade for ARM and HD in 2016. METHODS: The impact of a colostomy on the families and children's daily life was analyzed by personal interviews with a questionnaire. RESULTS: Twenty families with children were included in the study. Children's age ranged from 5 months to 27years (median 2.31). Annual income was reported to be less than $500 USD in 42.8%. Impairment of daily family life by the colostomy was reported in 85%. Parents of preschool children younger than 7 years are more affected than parents of older children, whereas children older than 7 years reported on more social problems. Moreover, 50% of the school-aged children did not attend school owing to issues directly related to their colostomy. DISCUSSION: Colostomies for children in the low middle-income country Honduras have significant social and economic implications for low-income families. In ARM and HD, medical brigades can offer help for definitive surgical repair to overcome and shorten the period of a colostomy presence to improve physical and psychosocial impairment, especially when performed before the children reach the school age. TYPE OF STUDY: Cost Effectiveness Study. LEVEL OF EVIDENCE: II.

Arterioportal shunting, splanchnic capillary perfusion, and the effects of colloids during capnoperitoneum in neonatal and adolescent pigs.

BACKGROUND: Clinical and experimental data indicate that neonates are sensitive to the CO2 pneumoperitoneum. An impaired splanchnic perfusion during laparoscopy in adults has been reported. We recently confirmed that intravenous colloids improve macrocirculatory function in neonates. We aimed to determine the impact of CO2 pneumoperitoneum on the perfusion of splanchnic organs in the young including effects of colloid application. METHODS: Male piglets (n = 25) were divided into four groups: (1) neonatal controls, (2) neonates with crystalloid restitution, (3) neonates with colloidal restitution, and (4) adolescents with crystalloid restitution. Animals were ventilated and subjected to a 3-h, 10 mmHg CO2 pneumoperitoneum followed by 2 h resuscitation. Hepatic, splanchnic, and arteriovenous shunt perfusion was assessed via central and portal venous catheters. Capillary organ flow was detected by fluorescent microspheres. The rate of bile flow was measured. RESULTS: The neonatal crystalloid group showed a significant decrease in the intestinal capillary perfusion at the end of the recovery period. This was not detectable in the adolescent and colloid group. There was a significant increase in microcirculatory arterioportal shunt flow during the CO2 pneumoperitoneum in both neonatal groups but not in the sham and adolescent groups (p < 0.05). Hepatic arterial perfusion increased after insufflation in all groups and dropped during capnoperitoneum to levels of about 70% baseline. There was no significant impairment of splanchnic perfusion or bile flow as a result of the pneumoperitoneum in all groups. CONCLUSIONS: Capillary perfusion of the abdominal organs was stable during capnoperitoneum and recovery in adolescents and neonates with colloid restitution, but not with crystalloid restitution. Significant arterioportal shunting during capnoperitoneum could affect hepatic microcirculation in neonates. Our data confirm that moderate pressure capnoperitoneum has no major effect on the perfusion of abdominal organs in neonates with adequate substitution.

[Minimally invasive pediatric surgery]. / Minimal-invasive Kinderchirurgie.

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.

Cardiovascular responses to prolonged carbon dioxide pneumoperitoneum in neonatal versus adolescent pigs.

BACKGROUND: Long-lasting minimally invasive procedures are increasingly used for children. However, the hemodynamic effects of a prolonged carbon dioxide (CO(2)) pneumoperitoneum (PP) on small infants are poorly understood and may differ from the effects on adolescents. This study aimed to detect and compare these effects in neonatal and adolescent pigs. METHODS: Six neonatal pigs weighing 5.6-6.4 kg and six adolescent pigs weighing 51-57 kg underwent a prolonged CO(2) PP of 180 min. Five neonatal pigs weighing 5.7-6.6 kg underwent sham PP as an additional control group. All the animals received crystalloid electrolyte solution at 10 ml/kg/h during the experiments. After CO(2) decompression, all the animals were monitored for a further 120 min. The end points of the study were mean arterial pressure (MAP), central venous pressure (CVP), and cardiac index (CI). The parameters were assessed after a 60-min resting phase (i.e., after initial placement of catheters in the jugular vein, the carotid artery, and the femoral artery four times during CO(2) PP and three times afterward. RESULTS: The comparison of neonates and adolescent pigs showed that neonates had a significantly more pronounced decrease in MAP during CO(2) PP (88.1 +/- 2.7% of baseline vs 95.1 +/- 1.6%; p < 0.05) and the recovery period (71 +/- 5.1% vs 86.4 +/- 1.4%; p < 0.05). Differences in CVP changes between the neonatal and adolescent pigs during and after CO(2) PP were not significant. For the neonates, the decrease in CI was most pronounced during the recovery period after decompression of the CO(2) PP and significantly less than in adolescents (84.3 +/- 3.3% of baseline vs 97.4 +/- 4.5%; p < 0.05). The neonates with sham PP did not show any significant MAP, CVP, or CI changes during the experiments. CONCLUSIONS: A prolonged CO(2) PP induces hypotension and cardiac depression in neonatal but not in adolescent pigs. Thus, intensive monitoring during prolonged laparoscopic procedures and particularly afterward may be mandatory for neonates.

[Minimally invasive paediatric surgery in other than paediatric surgical departments]. / Minimalinvasive Kinderchirurgie ausserhalb kinderchirurgischer Kliniken.

Minimally invasive techniques are well established in numerous paediatric surgical departments. They are safely applied to children of all age groups. Numerous types of procedures have been established specifically for children and, therefore, the necessary expertise cannot be derived from general surgical experience. Advantages in postoperative symptoms, convalescence and cosmesis have been confirmed. However, data or recommendations concerning the use outside of centres of paediatric surgery are lacking. In the opinion of the authors, minimally invasive paediatric surgery should only be considered for departments with a volume of paediatric specialty operations similar to that of paediatric surgical centres. In addition, an adequate number of operations, specific expertise of the surgeons in minimally invasive paediatric surgery, and specific expertise of anaesthesiologists is mandatory. Today, these prerequisites can only be assumed for non-paediatric specialty operations, such as laparoscopic appendectomy. In conclusion, before recommendations can be made for minimally invasive techniques in specialty paediatric operations outside of paediatric surgical centres, the feasibility and safety under these conditions has to be investigated.

[Cooperation model between an university clinic and a peripheral paediatric surgical department]. / Kinderchirurgische Kooperation zwischen einer Schwerpunktklinik und einem Versorgungskrankenhaus.

INTRODUCTION: The lack of young physicians in Germany, who are willing to train in surgery, is caused by several factors. Due to the demographic development and the specialisation in paediatric surgery in university institutions, attracting trained paediatric surgeons became difficult for non-specialised rural paediatric surgical departments, which is often also complicated by economic pressures. Strategies, such as cooperation between hospitals or departments, are required. We present a mid-term analysis of the first paediatric surgical cooperation between a university clinic and a rural paediatric surgical department in Lower Saxony. METHODS: The Department of Pediatric Surgery, Hannover Medical School (MHH), is a university centre with a case load of about 1,700 surgical procedures per year with a case mix index (CMI) of 1.3. The Department of Paediatric Surgery, St. Bernward Hospital Hildesheim (BK), is a peripheral institution with about 1,200 surgical procedures per year and a CMI of 0.5. A cooperation project was inaugurated in October, 2004, between the two departments. The aim of the cooperation was to support the head of the paediatric surgical department at the BK by rotating trained paediatric surgeons from the MHH. Simultaneously, it was planned to offer attractive conditions for research at MHH for participating surgeons. The cooperation further included sufficient economic cover of 1.5 posts for rotating medical staff by the BK. RESULTS: Three trained paediatric surgeons have so far been included in the rotation programme between the two cooperating paediatric surgical departments. The rotating medical staff costs were covered by the BK. Over a period of 2.5 years, MHH surgeons performed about 50 % of all surgical procedures at BK, while undertaking two-thirds of on-call duties there. Analysis of academic research revealed 3 accomplished experimental and 4 clinical studies, as well as 10 published articles. CONCLUSIONS: The paediatric surgical cooperation was rated as a success by the rotating trained paediatric surgeons, the heads of both departments and the hospital administrations. The academic link to a university clinic also increased the attractiveness to work in a paediatric surgical department at a rural hospital.

Impact of prior surgery on the feasibility of laparoscopic surgery for children: a prospective study.

BACKGROUND: This study aimed to determine the impact of prior surgery on the feasibility of laparoscopic surgery for children. METHODS: A prospective study analyzed 471 consecutive children who underwent laparoscopic surgery over a 4-year period. Laparoscopic procedures were classified "easy," "difficult," or "demanding." The end points of the study were conversion rate, intraoperative events, and duration of operation. RESULTS: A total of 89 patients (19%) had undergone previous abdominal surgery. The conversion rate was 18% for the patients with prior surgery versus 9% for those without a prior operation (16/89 vs 35/382; p < 0.05). This difference reflects a significantly higher conversion rate for "easy" procedures among patients with than among those without prior surgery, but not for "difficult" and "demanding" procedures. The type of prior surgery had no significant impact on the mean duration of the operation. Of 71 procedures, 12 (17%) after prior conventional surgery were converted, as compared with 4 (22%) of 18 after prior laparoscopy (p > 0.05). Intraoperative events, mainly attributable to adhesions and lack of overview, occurred in 8% of patients with prior procedures, as compared with 2% without former surgery (7/89 vs 9/382; p < 0.05). Relevant complications were not significantly more frequent after prior surgery. The incidence of conversions decreased with increased time between current and previous surgery. It was 64% for surgeries less than 1 year later, 25% for surgeries 1 to 5 years later, and 5% for surgeries more than 5 years later (7/11 vs 6/24 vs 3/54; p < 0.001). CONCLUSIONS: Prior surgery has a limited impact on the feasibility of laparoscopic surgery for children. The conversion rate and the incidence of intraoperative events, mainly because of adhesions and lack of overviewing, is increased, but not the incidence of relevant complications. The feasibility improves considerably with increased time between surgery and prior surgery. The authors consider laparoscopy to be the first-choice technique after prior surgery.

Laparoscopic nephroureterectomy in children: a prospective study on Ligasure versus Clip/Ligation.

PURPOSE: The present study was performed to compare dissection of the renal hilar vessels in laparoscopic transabdominal nephrectomy in children using the Endo-Ligasure vessel sealing system versus clip/ligation. PATIENTS AND METHODS: In a prospective and comparative study carried out from February 2003 to April 2004, 10 consecutive patients (group 1) underwent laparoscopic transabdominal nephroureterectomy using clips or intracorporeally performed ligations, respectively. From April 2004 to April 2005, 10 consecutive patients (group 2) underwent the same procedure using the Endo-Ligasure vessel sealing system. Indications for surgery were confirmed non-functioning kidneys secondary to benign unilateral renal disease and no prior surgery. The age and underlying disease distribution and the affected side were not significantly different between the two groups. RESULTS: The operating time was significantly lower in the Endo-Ligasure group (group 1: median 167 vs. group 2: 108 min, p < 0.05). Bleeding of the renal artery occurred due to dislocation of a suture ligation, which was treated laparoscopically with an intracorporeal suture ligation. Blood loss was negligible in all patients. All procedures were completed laparoscopically and recovery was uneventful. CONCLUSIONS: Endo-Ligasure is a beneficial tool in laparoscopic transabdominal nephrectomy. It is safe, effective, and reduces operating times compared to clip application and intracorporeal suturing.

Laparoscopic transperitoneal nephrectomy is feasible in the first year of life and is not affected by kidney size.

PURPOSE: We analyzed the feasibility of laparoscopic nephroureterectomy in children younger than 1 year, with regard to size of impaired kidney. MATERIALS AND METHODS: A total of 40 consecutive children underwent transperitoneal laparoscopic nephrectomy during a 4-year period. Of the patients 19 (48%) were younger than 1 year and were analyzed in detail. Nine of these patients (47.4%) had a multicystic dysplastic kidney, 9 (47.4%) had reflux nephropathy and 1 (5.3%) had obstructive nephropathy. The duration of operation, reasons for conversion, and intraoperative and postoperative complications were prospectively documented. RESULTS: Mean operative time was 133 minutes (range 60 to 240), and did not differ significantly between patients up to age 12 months compared to children 1 year and older (126 vs 148 minutes, NS). Nephroureterectomy was completed laparoscopically in 17 of 19 children (89%) up to age 12 months vs 20 of 21 (95%) 1 year and older (NS). In 1 child younger than 1 year suture dislocation at the renal artery required laparoscopic resuturing. No further complications were seen. In children younger than 1 year the mean operating time was not significantly different for resection of multicystic dysplastic kidney (8 patients, 113 minutes) compared to reflux nephropathy (9, 134 minutes, NS). Mean operating time did not differ significantly for kidney volumes less than 10 cc (8 patients, 119 minutes) compared to kidney volumes greater than 10 cc (9, 129 minutes, NS). CONCLUSIONS: The feasibility of transperitoneal laparoscopic nephroureterectomy in children younger than 1 year is excellent. The duration of operation is not affected by patient age, underlying disease or kidney size.

Laparoscopic transabdominal pyeloplasty in children is feasible irrespective of age.

PURPOSE: We assessed the feasibility of laparoscopic transabdominal dismembered pyeloplasty in 46 infants and children with regard to patient age. MATERIALS AND METHODS: A total of 46 consecutive infants and children (31 male and 15 female) underwent laparoscopic transabdominal dismembered pyeloplasty using a 3 to 4-trocar technique. All patients had confirmed unilateral deterioration of renal function on isotope renography. The 46 patients were divided into 3 age groups--1 to 12 months (group 1, 14 patients), 1 to 7 years (group 2, 15 patients) and 7 to 18 years (group 3, 17 patients). Followup included clinical and ultrasound assessment, and isotope renography at 3 months. RESULTS: Laparoscopic pyeloplasty was feasible in 44 of 46 patients (96%). Mean operative time was 175 minutes (range 120 to 270). The operation was converted due to impracticality of stenting the PUJ in 1 patient, and due to bleeding in 1. Mean operative time in 44 successful laparoscopic procedures was not significantly different among the 3 age groups (171 minutes in group 1, 169 minutes in group 2 and 173 minutes in group 3). Two patients required operative intervention for PUJ leakage, and 1 underwent percutaneous nephrostomy with a further uneventful course. Mean followup was 29 months (range 3 to 86). A total of 44 patients (96%) were asymptomatic and had improved PUJ drainage on isotope renography. Two patients underwent redo pyeloplasty due to recurrent hydronephrosis at 1 month and 2 years. CONCLUSIONS: Laparoscopic transabdominal dismembered pyeloplasty is effective and safe in infants and children. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without a disadvantage for the patient.

Laparoscopic partial external biliary diversion procedure in progressive familial intrahepatic cholestasis: a new approach.

BACKGROUND: Progressive familial intrahepatic cholestasis results in fibrosis, cirrhosis, and liver insufficiency if untreated. Medical therapy often fails and partial external biliary diversion has been recommended to prevent early liver transplantation. We present a new technique of performing a laparoscopic partial external biliary diversion and report our experience in a first series of infants. METHODS: From October to November 2004, four consecutive patients with progressive familial intrahepatic cholestasis underwent the laparoscopic partial biliary diversion procedure. A three-trocar technique was used. A proximal jejunal conduit was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel, an isoperistaltic cholecystojejunostomy was carried out laparoscopically. The distal jejunal conduit was placed as a stoma at the right abdominal trocar site. RESULTS: There were no intraoperative events. The mean duration of the operation was 156.5 min. The postoperative course was uneventful in all patients with full enteral feedings on day 2. The laboratory and clinical signs of cholestasis were reduced up to a mean follow-up of 2 months (range, 1.5-2.5). CONCLUSION: The laparoscopic partial biliary diversion procedure is feasible with all the benefits of minimally invasive surgery. Long-term results remain to be evaluated.