Contemporary trends in the use of primary repair for gastroschisis in surgical infants

BACKGROUND

Gastroschisis is a newborn anomaly requiring emergent surgical intervention. We review our experience with gastroschisis to examine trends in contemporary surgical management.

METHODS

Infants who underwent initial surgical management of gastroschisis from 1996 to 2014 at a pediatric hospital were reviewed. Closure techniques included primary fascial repair using suture or sutureless umbilical closure, and staged repair using sutured or spring-loaded silo (SLS). Data were separated into 3 clinical eras: pre-SLS (1996 to 2004), SLS (2005 to 2008), and umbilical closure (2009 to 2014).

RESULTS

In the pre-SLS era, 60% (34/57) of infants with gastroschisis underwent primary repair. With the advent of SLS, there was a decrease in primary repair (15%, 10/68, P < .0001). Following introduction of sutureless umbilical closure, 61% (47/77) of infants have undergone primary repair. On multivariate regression, primary repair was associated with shorter intensive care unit stays (P < .001) and time to initiate enteral nutrition (P < .01).

CONCLUSIONS

Following introduction of a less invasive technique for gastroschisis repair, most infants with gastroschisis were able to be repaired primarily. Primary repair should be considered in all babies with gastroschisis and favorable anatomy.

Robotic lateral pancreaticojejunostomy (Puestow)

A lateral pancreaticojejunostomy (LPJ), also known as the Puestow procedure, is a complex procedure performed for chronic pancreatitis when the pancreatic duct is dilated and unable to drain properly. Traditionally, these procedures are performed with open surgery. A minimally invasive approach to the LPJ using rigid handheld nonarticulating instruments is tedious and rarely performed. In fact, there are no prior laparoscopic case reports for LPJ in children and only a small handful of cases in the adult literature. This lack of laparoscopic information may be an indication of the difficulty in performing this complex operation with nonarticulating laparoscopic instruments. The advantages of robotic surgery may help overcome these difficulties. We present the first robotic LPJ ever reported in a 14-year-old child with idiopathic chronic pancreatitis. This case demonstrates the utility of this advanced surgical technology and may lead to a new minimally invasive option for both adults and children with chronic pancreatitis requiring surgical intervention.

Robotic repair of congenital diaphragmatic anomalies

PURPOSE

Congenital diaphragm anomalies, including eventration, Morgagni diaphragmatic hernias (M-CDH), and Bochdalek diaphragmatic hernias (B-CDH), have been successfully repaired by using minimally invasive surgery (MIS). However, some reports have shown a high recurrence rate for some defects, potentially due to difficulty associated with the rigid instruments. Robotic surgery may help close diaphragmatic anomalies more effectively. In this paper, we present a series of 8 consecutive patients with diaphragmatic anomalies who underwent robotic repair.

METHODS

We retrospectively reviewed patients with diaphragmatic anomalies. There were 2 patients with eventration, 5 with B-CDH, and 1 with M-CDH. All procedures were performed by using the Standard Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm (5-mm two-dimensional scope) and two instrument arms (5 mm).

RESULTS

Average age was 3.9 months (4 days to 12 months). Average weight was 3.6 kg (range, 2.2-10.5). Four B-CDH patients were approached through the chest and 1 from the abdomen. The patient with M-CDH had an abdominal repair, and both eventrations were performed from the chest. One B-CDH and 1 eventration were converted to thoracoscopic procedures. Average operative time was 1 hour and 20 minutes. One recurrence developed in a relatively large B-CDH repair that was closed primarily. Average follow-up was 20 months.

CONCLUSIONS

Robotic surgery is safe and effective for repairing diaphragm anomalies in small children. Although we prefer the thoracic approach for repairing the B-CDH, occasionally smaller newborns-perhaps those less than 2.5 kg-may do better with the abdominal approach, since the articulating instruments requiring a significant length in order to maneuver.

Robotic resection of mediastinal masses in children

PURPOSE

Robotic surgery may be particularly well suited for solid chest masses. In this paper, we present our initial experience by using robotic surgery to resect mediastinal masses in children.

METHODS

Five pediatric patients with an average age of 9.8 years (range, 2-17) and an average weight of 41.5 kg (range, 13.9-70.5) underwent a robotic resection of a mediastinal chest mass using the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA).

RESULTS

Operative time ranged from 44 to 156 minutes, with an average of 113 minutes. The pathology varied considerably and included a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. No complications or conversions occurred. Average length of hospitalization was 1.4 days. Follow-up averaged 2 years, with no evidence of recurrence in any patient.

CONCLUSIONS

Robotic surgery is safe and effective for resecting solid mediastinal chest masses. The articulating instruments are particularly helpful for dissecting around a solid mass within the rigid thoracic cavity.

Common bile duct perforation resulting from a gastric duplication cyst

Gastric duplication cysts are a rare cause of abdominal masses in infants. Most children present with a gastric outlet obstruction or some vague abdominal complaints. We present an unusual case of a gastric duplication cyst that created a distal common bile duct obstruction which led to a proximal common bile duct perforation.

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.

Robotic fundoplication in children: resident teaching and a single institutional review of our first 50 patients

BACKGROUND

Robotic surgery is a new technology that may eventually replace laparoscopy in treating many surgical issues in children. Resident education using robotic surgery has been a concern for many institutions. We present our first 50 consecutive robotic fundoplications in children and our teaching experience with this procedure.

METHOD

A 3-arm surgical robot was used to create a Nissen fundoplication with 1 additional port for liver retraction. Although there were exceptions, a 12-mm 3-dimensional camera was used in most patients greater than 10 kg, and a 5-mm 2-dimensional camera if less than 10 kg. Robotic instruments were either 8 or 5 mm. An accessory port was used for liver retraction. The console surgeon was either an attending surgeon or a fourth-year general surgery resident. The general surgery residents had limited prior minimally invasive experience consisting of cholecystectomies, appendectomies, and a few other procedures.

RESULTS

Average age was 5.1 years (range, 1 month to 16 years). Average weight was 19.5 kg (range, 2.7-96.4 kg). No open conversions or intraoperative complications occurred. Postoperative complications included ileus (4%), dysphagia (4%), a G-tube site wound infection (2%), gas bloat syndrome (2%), and 1 wrap breakdown 3 years after the initial procedure (2%). Operative times for staff surgeons were down to 90 minutes after 5 fundoplications.

CONCLUSION

Robotic fundoplication is an acceptable method to perform minimally invasive antireflux surgery in children. Resident education and teaching can be readily accomplished using the robot and the learning curve is relatively short and steep.

The robotic approach to complex hepatobiliary anomalies in children: preliminary report

PURPOSE

Robotic technology allows surgeons to perform complex procedures which may be difficult with standard laparoscopic instruments. We believe that complex hepatobiliary procedures are ideally suited for robotic surgery in children and present our experience with Kasai portoenterostomy and excision of choledochal cysts.

METHODS

We performed 4 complex hepatobiliary procedures in children using the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA): 2 Kasai portoenterostomies and 2 choledochal cyst resections. Both Kasais had the Roux-en-Y jejunojejunostomy performed extracorporeally through the 12 mm umbilical trocar site. Both choledochal cysts had the Roux-En-Y jejunojejunostomy performed intracorporeally. All patients had their hepatobiliary to enteric anastomosis performed intracorporeally.

RESULTS

Total average time was 6 hours and 12 minutes for the Kasai and 7 hours and 38 minutes for the choledochal cysts. The average robotic console time for all cases was 6 hours. No intraoperative or perioperative complications occurred. Average length of hospital stay was 4 days. Both choledochal cyst patients were doing well after 9 and 12 months with no complications. One Kasai patient is doing well 14 months after Kasai with a normal bilirubin. The other Kasai patient did well for a year with a normal bilirubin. However, the patient slowly developed intrahepatic bile lakes despite a normal bilirubin and a well draining Kasai as demonstrated by hepatobiliary iminodiacetic acid (HDA) scan. He began having recurrent episodes of cholangitis and we referred him for liver transplantation.

CONCLUSION

Minimally invasive robotic complex hepatobiliary surgery is safe and effective in children. The 3-dimensional imaging and improved articulations make these procedures particularly suited for robotics over standard laparoscopy.

Robotic repair of a Bochdalek congenital diaphragmatic hernia in a small neonate: robotic advantages and limitations

Minimally invasive repair for a Bochdalek congenital diaphragmatic hernia has been performed over the last few years with mixed results. Although the anomaly has been approached from both the abdomen and the chest, the defect can be difficult to close as the posterolateral region may be difficult to reach with precise suturing using standard rigid laparoscopic instruments. The articulating instruments of robotic surgery offer a substantial improvement in degrees of freedom and may help over come these obstacles. However, other limitations including instrument length in relation to patient size need to be accounted for when planning a robotic procedure in small children. We present a robotic repair of a foramen of Bochdalek congenital diaphragmatic in a 2.2 kg neonate using and abdominal approach with the Da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA).

Robotic repair of congenital duodenal atresia: a case report

Although repair of duodenal atresia has been performed laparoscopically, it can be a difficult procedure using rigid handheld laparoscopic instruments. Only a few pediatric surgeons are performing this operation with a minimally invasive approach. Robotic surgery may help overcome the obstacles presented by the use of traditional rigid laparoscopic instruments. We present the world's first robotic repair of congenital duodenal atresia in a 2.4-kg, 1-day-old newborn. The procedure took less than 3 hours, and the patient had an unremarkable postoperative course.

Pediatric robotic surgery: A single-institutional review of the first 100 consecutive cases

BACKGROUND

Robotic surgery is a new technology which may expand the variety of operations a surgeon can perform with minimally invasive techniques. We present a retrospective review of our first 100 consecutive robotic cases in children.

METHODS

A three-arm robot was used with one camera arm and two instrument arms. Additional accessory ports were utilized as necessary. Two different attending surgeons performed the procedures.

RESULTS

Twenty-four different types of procedures were completed using the robot. The majority of the procedures (89%) were abdominal procedures with 11% thoracic. No urology or cardiac procedures were performed. Age ranged from 1 day to 23 years with an average age of 8.4 years. Weight ranged from 2.2 to 103 kg with a median weight of 27.9 kg. Twenty-two patients were less than 10.0 kg. Examples of cases included gastrointestinal (GI) surgery, hepatobiliary, surgical oncology, and congenital anomalies. The overall majority of cases had never been performed minimally invasively by the authors. The overall intraoperative conversion rate to open surgery was 13%. One case (1%) was converted to thoracoscopic because of lack of domain for the articulating instruments. No conversions or complications occurred as a result of injuries from the robotic instruments. Interestingly, four abdominal cases were converted to open surgery due to equipment failures or injuries from standard laparoscopic instruments used through non-robotic accessory ports.

CONCLUSIONS

Robotic surgery is safe and effective in children. An enormous variety of cases can be safely performed including complex cases in neonates and small children. Simple operations such as cholecystectomies have minimal advantages by using robotic technology but can serve as excellent teaching tools for residents and newcomers to this form of minimally invasive surgery (MIS). The technology is ideal for complex hepatobiliary cases and thoracic surgery, particularly solid chest masses.

Surgical treatment of a gastric diverticulum in an adolescent

Gastric diverticula are uncommonly seen in childhood. They typically emanate from the posterior wall of the stomach near the gastroesophageal junction. The authors report on a 15-year-old adolescent boy who presented with a symptomatic gastric diverticulum that was surgically resected. Potential pitfalls in diagnosis and treatment are discussed.

Extrapleural benign solitary fibrous tumor in the shoulder of a 9-year-old girl: case report and review of the literature

We report a case of a benign solitary fibrous tumor that occurred in the right shoulder of a 9-year-old girl. This case is remarkable due to the unusual location of its occurrence and the young age of the patient. In addition, cytogenetic analysis revealed a karyotype unreported in this neoplasm: 46,XX,der(4)t(4;9)(q31.1;q34), del(9)(p22p24),der(9)t(4;9)(q31.1;q34)ins(9;?)(q34;?) (17 cells)/46,XX (3 cells).

Outcome after recannulation and a second course of extracorporeal membrane oxygenation

BACKGROUND/PURPOSE

Controversy surrounds the justification of a second course of extracorporeal membrane oxygenation (ECMO) for patients that deteriorate after initial decannulation. The authors' experience with a small number of patients requiring recannulation led them to investigate the results of a second ECMO course from all institutions that report to the ELSO registry.

METHODS

The ELSO neonatal registry for patients that underwent multiple ECMO courses was reviewed and mortality and complication rates between first and second courses were compared. Complications were classified according to the following ELSO registry defined categories: hemorrhagic, mechanical, metabolic, infectious, renal, pulmonary, neurologic, and cardiac.

RESULTS

Of the 16,450 patients in the ELSO neonatal registry in January 2000, 205 patients (1.25%) have required multiple ECMO courses. There have been 201 patients (1.22%) who have needed 2 courses of ECMO and 4 patients (0.024%) have undergone 3 ECMO runs. A total of 557 complications occurred during the first ECMO course in these 205 patients, and 672 complications developed during the second course. This represents an increase in the complication rate by 20.6% during the second ECMO course. Although mechanical complications were the most common, there was no change in the incidence between first and second courses. However, the frequency of complications increased in all other classifications during the second course when compared with the first. The largest increases occurred with neurologic and infectious complications (134% and 79% increases, respectively). Renal and metabolic complications also were markedly elevated (35% and 24%, respectively). Seventy-six of 201 (38%) patients who required 2 courses of ECMO and 1 of 4 patients undergoing 3 runs survived. Survival was more likely for patients with meconium aspiration. Primary pulmonary hypertension and total anomalous pulmonary venous return had low survival rates.

CONCLUSIONS

A small subset of patients may require recannulation and a second ECMO course. Although survival may be achieved in more than one third of these patients, complication rates are increased during the second course. Specifically, neurologic, infectious, renal, and metabolic complication rates are increased. Long-term consequences of recannulation are unknown. Selection criteria identifying patients that may benefit from recannulation have not been established.

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.

The learning curve associated with laparoscopic antireflux surgery in infants and children

Laparoscopic fundoplication is an effective method for treating gastroesophageal reflux in infants and children. Some surgeons prefer the traditional open technique and have concerns regarding complications associated with laparoscopic surgery as well as the time length of operation. This report addresses these concerns in a retrospective review of the first 160 consecutive pediatric patients who underwent laparoscopic fundoplication. "Learning Curves" as a function of surgical experience are presented highlighting some of the lessons learned while developing the laparoscopic fundoplication technique.

Prevention of liver failure in parenteral nutrition-dependent children with short bowel syndrome

Progressive liver failure in parenteral nutrition (PN)-dependent children with short bowel syndrome carries significant morbidity and mortality. The authors retrospectively reviewed 47 consecutive patients with short bowel syndrome diagnosed from October 1985 through October 1995. All patients were treated according to a protocol designed to promote intestinal motility and discourage bacterial translocation. Elements of the protocol included the use of taurine, vigilant prevention and aggressive treatment of sepsis, meticulous catheter care, early PN cycling, appropriate enteral feeding, and measures designed to inhibit gastrointestinal bacterial translocation, especially gram-negative rods. Complete blood counts and serum liver function studies were compiled from both clinic visits and hospital admissions for each patient every 3 to 6 months while they were on PN. Three patients were lost to follow-up after they had moved out of state. The length of time on PN ranged from 3 months to 9.4 years with an average of 2.2 years. Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and glutamyltransferase (GGT) were present in 82%, 66%, and 84% of patients, respectively. Alkaline phosphatase was elevated in 58% of patients. Eight patients (18%) are still on PN, and 31 (70%) have been weaned off PN. Five patients have died (11%). Three patients (7%) developed cholecystitis requiring cholecystectomy. No patients developed progressive liver failure. These results suggest that PN-related liver failure may be prevented in most patients with short bowel syndrome. Specific measures to prevent PN-related cholestatic jaundice need further investigation.

Laparoscopic fundoplication in infants and children

BACKGROUND

Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication.

METHODS

Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures.

RESULTS

Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%).

CONCLUSION

Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication.

Postburn respiratory injuries in children

Respiratory tract injury is a leading cause of mortality, morbidity, and prolonged hospitalization in fire casualties. Direct insults include inhalation of superheated gas, steam, smoke, or toxic fumes. Indirect injury may result from interference with the mechanics of respiration. Pulmonary injuries result from sepsis, fluid overload, endogenous reactive substances, and "shock lung," and also occur secondary to metabolic disturbances resulting from hypoxia.