Antonella Centonze

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease

BackgroundNissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures.MethodsThis study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created.ResultsThe median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann–Whitney U test are not statistically significant.ConclusionsFor pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon’s experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

Laparoscopy-Assisted Orchidopexy: An Ideal Treatment for Children with Intra-Abdominal Testes

BACKGROUND AND PURPOSE The investigation of a child with a nonpalpable testis is probably the most frequent indication for laparoscopy in pediatric patients. The objective of this study was to evaluate the results and advantages of laparoscopy-assisted orchidopexy performed without dividing the spermatic vessels. PATIENTS AND METHODS During a 3-year period, 85 boys with nonpalpable testes (NPT) (91 testes overall) underwent laparoscopic diagnostic exploration. Twenty-five patients (27.4%) showed an intra-abdominal testis (IAT): 24 underwent a laparoscopy-assisted orchidopexy (LAO) without sectioning of the spermatic vessels, and one, whose inner spermatic vessels were not adequately long for LAO without tension, underwent a two-step Fowler-Stephens (FS) procedure. The technique consists of dissection and mobilization of the inner spermatic vessels and the vas deferens from the posterior peritoneum, sectioning of the gubernaculum attachments, and bringing down of the testis into the scrotum through the internal inguinal ring, if open, or through a neo-inguinal ring created medial to the epigastric vessels. RESULTS Surgery lasted between 40 and 80 minutes (median 60 minutes). All the testes were brought down into the scrotum. There was only 1 (4%) intraoperative complication, which occurred in the second patient operated on with this procedure. He experienced an iatrogenic rupture of the spermatic vessels secondary to excessive traction. CONCLUSION Laparoscopic orchidopexy is the logical extension of diagnostic laparoscopy for the evaluation of NPT. Concerning the technique, we believe that LAO with intact spermatic vessels could be considered the treatment of choice in the patient with IAT, as it does not affect normal testicular vascularization. Alternatively, in the case of very high IAT (more than 3 cm from IIR), an FS procedure may be considered.

Laparoscopic antireflux procedures in the management of gastroesophageal reflux following esophageal atresia repair.

Objectives: The validity of open fundoplication after esophageal atresia (EA) repair is still disputed. The authors have retrospectively evaluated the results achieved in their centers using laparoscopic antireflux procedures (LARP) in children operated for EA at birth. Methods: From 1998 to 2002, 350 children underwent LARP. Of these, 21 (6%) underwent EA repair at birth. Our study focused only on the management of these 21 patients; 5 of them (23.8%) were neurologically impaired children (NIC). All underwent LARP, 9 patients according to Nissen, 9 according to Thal, and 3 according to Toupet. The 5 NIC with feeding problems underwent concomitant g-tube placement during the same procedure. Results: All the procedures were completed in laparoscopy, without intraoperative complications. The mean operative time was 65 minutes (range 45-140). We had no mortality in our series. Hospital stay varied from 2 to 9 days (median 3 days). At a maximum follow-up of 6 years, all patients were evaluated with a 24-hours pH-metry and barium swallow. The 16 neurologically normal children were free of symptoms at the last follow-up; five of them (31.2%) had mild dysphagia, which disappeared spontaneously within 3-6 months. One girl experienced an important episode of aspiration 2 years after the LARP, although there was no evidence of reflux at the follow-up examinations. As for the 5 NIC, one patient eats only through a g-tube, the other 4 undergo mixed feeding (g-tube and mouth); none have signs of GER, but two of them still present respiratory symptoms, and one has delayed gastric emptying. Conclusions: In our experience laparoscopic antireflux surgery is an appropriate treatment of GER in children operated for EA at birth, independently of the antireflux mechanism adopted; the 31.2% rate of short-term dysphagia presenting as residual respiratory symptoms may be due to a primary dysmotility of the esophagus consequent to the esophageal atresia.

Comparison of five different hormonal treatment protocols for children with cryptorchidism.

OBJECTIVE To compare the effects of medical therapy on boys with cryptorchidism, a prospective study was carried out in five groups of patients over a 30-month period. MATERIAL AND METHODS A total of 439 boys with undescended testicles were enrolled; their ages ranged between 6 months and 13 years (median 4.2 years). Of these, 327 had true unilateral and 112 bilateral undescended testicles. In 115 patients surgery was performed directly either because the condition was associated with inguinal hernia or because the child had undergone previous inguinal surgery; hormonal treatment was attempted in the remaining 324 patients. Human chorionic gonadotrophin (hCG) was administered to 113 patients (34.8%), luteinizing hormone-releasing hormone (LH-RH) to 85 (26.2%), a combination of LH-RH and hCG to 64 (19.7%), human menopausal gonadotrophin (hMG) to 35 (10.8%) and a combination of hMG and hCG to 27 (8.3%). RESULTS Overall, testicular descent was achieved in 27.7% (90/324) of patients: specifically, in 38.2% (36/94) of boys with bilateral undescended testicles (both testes in 22/36, one testis only in 14/36) but in only 23.4% (54/230) of those with unilateral undescended testicles (p = 0.007). The correlation between the type of therapy and testicular descent can be summarized as follows: hCG, 39/113 (34.5%); LH-RH, 25/85 (29.4%); hCG+LH-RH, 19/64 (29.6%); hCG+hMG, 7/27 (25.9%); hMG alone, 0/35 (0%). CONCLUSIONS In our experience, pharmacological treatment seems to yield better results in cases of bilateral than unilateral cryptorchidism. hCG seems to be equally effective as LH-RH for the treatment of cryptorchidism in approximately 30% of cases; the combination of these two drugs does not seems to increase the success rate. The use of hMG alone is ineffective. We believe that hormonal treatment can lead to acceptable results in boys with cryptorchidism, without relevant adverse effects.

Experience with the use of tissue adhesives in pediatric endoscopic surgery

Background: Due to technological improvements, the use of tissue adhesives and glues for tissue approximation and hemostasis in surgery has increased. We report our preliminary experience with this technology in pediatric endosurgery. Methods: Between 1997 and 2000, we employed tissue adhesives in 48 pediatric patients during laparoscopic procedures. In 25 patients, the glue was adopted for the hemostasis of parenchimal organs (liver in 24 cases and spleen in one). In three cases, the glue was used to repair organ perforation, in 19 it was used to close the distal part of a patent processus vaginalis in case of congenital inguinal hernia. In the final case, the glue was adopted to achieve optimal airtightness in case of pulmonary biopsy. The glue was injected with the aid of a needle positioned transparietally. Results: The procedure was easy and rapid in all cases, and there were no problems or complications related to glue positioning at a mean follow up of 51 months. Conclusion: Tissue adhesives are a very versatile product for use in pediatric laparoscopic surgery. It is likely that their usage will increase as the technology improves and more effective products are developed.

One-trocar laparoscopy

Background: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). Materials and Methods: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. Results: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. Conclusions: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

Laparoscopic-assisted jejunostomy : An effective procedure for the treatment of neurologically impaired children with feeding problems and gastroesophageal reflux

BackgroundFeeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients.MethodsSince January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy.ResultsSurgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children.ConclusionsLaparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients’ feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

Laparoscopic-assisted jejunostomy

BackgroundFeeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients.MethodsSince January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy.ResultsSurgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children.ConclusionsLaparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients’ feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.

The efficacy of laparoscopy in detecting and treating associated congenital malformations in children

One of the main advantages of laparoscopy in children is the fact that it enables a magnified view and the possibility to explore the whole abdominal cavity. This case report clearly shows these advantages. We report the case of a 3-yr-old girl, suffering from severe GERD and right inguinal inguinal hernia, who had already been operated at birth for esophageal atresia. We performed a laparoscopic fundoplication according to Nissen and, at the end of procedure, we decided to turn the optic down to control the right inguinal region to confirm the presence of an inguinal hernia. To our great surprise we found a right oblique external hernia as well as a direct inguinal hernia on the same side. Both hernias was treated successfully in laparoscopy. At a 1-year follow-up, the patient presented no reflux and no recurrence of the inguinal hernias. The laparoscopy in this case permitted operation on two different pathologies involving the upper and lower parts of the abdominal cavity using the same ports and without enlarging the incision, as would happen in laparotomy. The main relevance of this case is that laparoscopy allowed the detection of an associated pathology like a direct inguinal hernia that would have been certainly overlooked in open surgery and could have caused a recurrent hernia if operated via open surgery.