Laparoscopic management of gallbladder disease in children and adolescents.

BACKGROUND: Between July 1991 and April 1996, 40 children and adolescents age 17 or less underwent laparoscopic management of their gallbladder disease. Twenty-eight patients were females and 12 were males. Their average age was 12.7 years (range 2-17 years), and average weight was 50 kilograms, range 12.2-95.9 kilograms. Nine patients had gallstone pancreatitis and seven patients had sickle cell disease. Laparoscopic cholecystectomy was attempted in all patients with or without modifications of the standard technique dictated by the size of the patient. METHODS: The practice of intraoperative cholangiogram varied with the practicing surgeon. Those with clinical or biochemical evidence of common bile duct obstruction underwent preoperative endoscopic retrograde cholangiopancreatography to rule out other causes of hyperbilirubinemia and/or therapy for choledocholithiasis if present. Patients with unsuccessful intraoperative cholangiogram were followed clinically and were subjected to postoperative endoscopic retrograde cholangiopancreatography should they develop clinical or biochemical evidence of common bile duct obstruction. Thirty-six patients were completed laparoscopically (90%). Four patients were converted to open cholecystectomy (10%). Four patients required preoperative endoscopic retrograde cholangiopancreatography and were successfully treated. Postoperative endoscopic retrograde cholangiopancreatography was unsuccessful in one patient who required the procedure because of retained common bile duct stone. Four patients suffered complications (10%). Three patients continued to have abdominal pain that was not helped with surgery. CONCLUSIONS: Based on our experience, laparoscopic cholecystectomy with preoperative endoscopic retrograde cholangiopancreatography if required, is safe and effective in management of gallbladder disease in children and adolescents. However, careful preoperative evaluation is required to avoid persistent postoperative abdominal pain.

Video-assisted thoracic surgery: applications and outcome.

Thoracoscopy has been revived and expanded by recent improvements in endoscopic technology. The enhanced application and outcome of VATS (video assisted thoracic surgery) was retrospectively studied. Between 1992 and 1995, 82 patients underwent diagnostic thoracoscopy or interventional VATS. Indications included: shortness of breath with nonspecific x-ray abnormality (45%), pulmonary nodule (25%), pleural effusion/empyema (21%), pneumothorax (14%), and hemoptysis, chronic cough or lung consolidation (5%). Sixty-six (83%) of the procedures were completed thoracoscopically. Eight procedures (10%) required addition of a utility mini-thoracotomy and 6 procedures (7%) were converted to formal thoracotomy. Specific diagnostic and/or therapeutic applications of VATS included: inspection; lysis of adhesions; stapling of blebs; biopsy of lung, pleura, or mediastinal structures; drainage and decortication of empyema; mechanical and chemical pleurodesis; wedge resection; and segmental resection. Diagnosis was established and/or treatment completed in 95% of cases. Pathologic diagnoses included: interstitial pneumonitis (22%), cancer (19%), bullous disease (15%), cocci nodule (9%), and other (18%). There were twenty-two complications (28.9%) and four deaths (4.8%). All four deaths were from causes unrelated to the surgery. The most common complications were: residual pneumothorax or hydrothorax (7), failed pleurodesis (3), and prolonged incisional pain (2). The advantage of reduced chest wall and muscle trauma utilizing VATS as opposed to traditional thoracotomy translates to less patient discomfort. The excellent magnified visualization afforded by VATS offers the opportunity to successfully conduct diagnostic and therapeutic interventions in the chest with equal or better visibility. Our findings suggest that the applicability and success of VATS is greatly expanding and its complication rate is less or, at worst, comparable to traditional thoracotomy.

Diagnostic laparoscopy in women with acute abdominal pain.

Nineteen women with acute lower abdominal pain of uncertain etiology underwent diagnostic laparoscopy during a 2-year period from August 1991 to August 1993 and were retrospectively reviewed. All patients, aged 12 to 44 years, were premenopausal. Laparoscopy provided definitive diagnosis in all 19 patients. Laparoscopic findings included appendicitis (11 cases), pelvic inflammatory disease (five cases), significant ovarian cysts (two cases), and ectopic pregnancy (one case). Successful laparoscopic procedures included appendectomy (five cases), and salpingo-oophorectomy (one case). Five patients required only diagnostic laparoscopy. Eight patients required conversion to an open procedure because of anatomical considerations (six cases) or equipment failure (two cases). Median operative time was 71 min, and median postoperative hospital stay was 2 days. Most diagnostic procedures were performed on the same day as admission, resulting in a median hospital stay of 3 days. Diagnostic laparoscopy performed in premenopausal female patients with acute lower abdominal pain of unknown etiology provides diagnostic accuracy as well as therapeutic capabilities and prevents unnecessary laparotomy.

Laparoscopic management of gallstone pancreatitis.

Thirty-seven patients with gallstone pancreatitis were encountered over a 28-month period from June 1990 to October 1992. The use of laparoscopic cholecystectomy with intraoperative cholangiography in the management of gallstone pancreatitis was retrospectively studied. Thirty-two women and 5 men ranged in age from 16 to 74 years. Admitting amylase levels ranged from 241 to 5547 IU/L. No patient had a clinical history consistent with other causes of pancreatitis. Initial treatment consisted of bowel rest until amylase levels had normalized and abdominal tenderness had resolved. Twenty-nine of 37 patients were initially treated laparoscopically, but 7 required conversion to open cholecystectomy. Choledocholithiasis was identified intraoperatively in 4 patients. These stones were cleared either laparoscopically (2), by open common bile duct exploration (1), or by postoperative endoscopic retrograde cholangiopancreatography (1). Patients treated laparoscopically had a median postoperative discharge time of 1.0 day vs 3.5 days for those treated by open technique. Not all patients with gallstone pancreatitis can be treated successfully using laparoscopic techniques. As the experience and confidence of surgeons increases, laparoscopic management of gallstone pancreatitis is appropriate, with open conversion as necessary.

Thymic carcinoid.

Carcinoid of the thymus is a rare neoplasm. Differentiation from thymoma is important because they have entirely different prognosis. A patient in whom a 19 x 18 x 12 cm carcinoid tumor of the thymus was surgically removed is presented. The tumor metastasized to peritracheal and internal mammary nodes, and invaded the SVC, pleura, lung, and pericardium. This is apparently the largest reported tumor of its kind. Prior to induction of anesthesia cardiopulmonary bypass and rigid bronchoscopy were readily available. Awake intubation was utilized. Even though long-term prognosis is poor, an aggressive surgical approach and adjuvant radiotherapy may achieve extended survival with excellent quality of life. Central aspects of the disease as well as pivotal therapeutic points are discussed.

Intra-abdominal seatbelt injury.

The use of seatbelts has significantly decreased the mortality and morbidity of injuries caused by motor vehicle accidents. We present eight patients who sustained severe intra-abdominal injuries peculiar to the use of the seatbelt. Serious injuries to the bowel and mesentery may be present without early symptoms or physical signs and neither CT scanning nor diagnostic peritoneal lavage is fully reliable or accurate in finding the injury. Prompt diagnosis may be difficult and requires a high index of suspicion as well as a determined approach that may include exploratory celiotomy. The presence of a seatbelt sign across the abdomen is not incontrovertible evidence that a laparotomy must be done, but its presence should create a high index of suspicion for serious visceral injury. Delay in diagnosis significantly increases morbidity and is associated with high mortality rates.

Salmonella vertebral osteomyelitis: a complication of salmonella aortitis.

Salmonella vertebral osteomyelitis of the lumbar spine is encountered as a complication of Salmonella arteritis. Salmonella organisms, especially those of the choleraesuis and typhimurium species, invade the lamina intima of a diseased or atherosclerotic abdominal aorta, penetrate its wall, and cause the formation of a mycotic aneurysm. Further spread of thé infectious process through the aneurysmal aortic wall leads to infection of the retroperitoneum, psoas abscess formation, and osteomyelitis of the adjacent lumbar vertebrae. A review of the literature reveals a 77% mortality rate. Successful treatment of this association requires resection of the abdominal aneurysm and debridement of the retroperitoneum, extra-anatomic bypass grafting, and appropriate antimicrobial therapy.Key Indexing Terms: Salmonella Vertebral Osteomyelitis; Salmonella Aortitis; Mycotic Aortic Aneurysm.

Central vessel trauma.

During a 24 month period, 30 patients were treated for central vessel trauma (CVT). Injured vessels included all of the major arteries and veins in the chesk, neck and abdomen except the infrarenal aorta. Overall survival was 70 per cent. Experience with specific injuries is reviewed with commentary on surgical access to difficult areas including the thoracic outlet, suprarenal aorta and inferior vena cava. Common factors in the nine deaths are reviewed with the findings that cardiac arrest at any time during pre- or intraoperative management is uniformly lethal; emergency thoracotomy for control of bleeding carries an expectedly high mortality; cross-clamping of the descending thoracic aorta to control hemoperitoneum has a limit of tolerance of about one hour, and prolonged shock, whether compensated or profound is poorly tolerated and is associated with a high mortality.