Conrad W. Wesselhoeft

Incidence of contralateral inguinal hernia: A prospective analysis

BACKGROUND/PURPOSE Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The authors have attempted to determine the age- and gender-stratified incidence of contralateral hernia and the necessity of routine bilateral procedures. METHODS This is a prospective study of 656 patients during a 34-month period at a single institution. Patients with unilateral hernia underwent an ipsilateral procedure only, regardless of age, gestational age, or gender. Follow-up was 6 to 40 months (mean, 25.5 months). Chi-square analysis was used for intergroup comparison (P < .05 significant). RESULTS Of 656 children, 108 (16.5%) presented with synchronous bilateral hernias. Bilateral inguinal hernia was significantly more common in premature infants (28.0%) and young children (33.8% if <6 months, 27.4% if <2 years). Of the remaining 548, a metachronous contralateral hernia developed in 48 (8.8%) at a median interval of 6 months (range, 4 days to 7 years). This incidence was 13 of 105 (12.4%) in infants less than 6 months of age, 20 of 189 (10.6%) in children less than 2 years of age, 8 of 54 (14.8%) in premature infants, 6 of 81 (7.4%) in girls, and 8 of 29 (27.6%) in children with an incarcerated hernia. In the latter group, P < .05, chi2 analysis. CONCLUSION Routine contralateral inguinal exploration, without clinical evidence of a hernia, may be advisable in children with incarceration and possibly in premature infants. The low incidence of contralateral hernias in all other patients, regardless of gender or age, does not justify routine contralateral exploration.

Open and laparoscopic appendectomy are equally safe and acceptable in children

Background: The aim of this study was to evaluate prospectively whether laparoscopic (LA) and open appendectomy (OA) are equally safe and feasible in the treatment of pediatric appendicitis. Methods: A total of 517 children with acute appendicitis were randomly assigned to undergo LA or OA appendectomy, based on the schedule of the attending surgeon on call. Patient age, sex, postoperative diagnosis, operating time, level of training of surgical resident, length of postoperative hospitalization, and minor and major postoperative complications were recorded. Chi-square analysis and the Student t-test were used for statistical analysis. Results: In all, 376 OA and 141 LA were performed. The two groups were comparable in terms of patient demographics and the incidence of perforated appendicitis. The operative time was also similar (47.3 ± 19.7 vs 49.9 ± 12.9 min). The overall incidence of minor or major complications was 11.2% in the OA group and 9.9% in the LA group. Conclusion: Pediatric patients with appendicitis can safely be offered laparoscopic appendectomy without incurring a greater risk for complications. Nevertheless, a higher (but not significantly higher) abscess rate was found in patients with perforated appendicitis who underwent laparoscopy.

Benefits of term delivery in infants with antenatally diagnosed gastroschisis

Abstract OBJECTIVE: To test the hypothesis that term gestation offers the best outcome. The relationship between gestational age and the extent of bowel injury in fetuses with gastroschisis is a matter of debate. Early delivery and cesarean delivery have been recommended to limit intestinal damage, but their benefits are unclear. METHODS: Data on all patients with gastroschisis seen at our institution from 1991 through 2001 were included. Patients were compared based on gestational age: less than 35 weeks, 35–37 weeks, and term (more than 37 weeks) with regard to age at definitive closure, age at first and full feedings, and hospital stay. Statistical significance (P RESULTS: Of the 57 patients, 19.3%, 43.8%, and 36.9% were born at less than 35 weeks, 35–37 weeks, and more than 37 weeks, respectively. Age at definitive closure was significantly higher at 35–37 weeks (5.9 ± 4.6 days) than at more than 37 weeks (1.5 ± 2.3 days) and less than 35 weeks (2.6 ± 2.5 days) (P CONCLUSION: Based on a homogeneous cohort of patients in whom gastroschisis was diagnosed antenatally, term delivery results in earlier closure of the defect and shorter time to full feedings. The benefit of early delivery postulated by others cannot be substantiated.

Primary laparoscopic placement of peritoneal dialysis catheters in children and young adults

AbstractBackground: Primary placement of peritoneal dialysis catheters in children often requires suturing of the catheter into the pelvis. We describe our experience with a gasless laparoscopy technique in children and young adults. Methods: During an 18-month period, 12 patients (mean age, 14 years) underwent primary laparoscopic placement of peritoneal dialysis catheters. A single umbilical port was used for abdominal wall elevation, telescope, and catheter. A needleholder was introduced via an accessory port at the future catheter exit site or through the umbilical port. Omentectomy was performed through the umbilical incision. The catheter was tunneled to the lateral abdominal wall. Follow-up data (≥15 months) included time to initiation of dialysis, hospitalization, and outcome. End points were cure, transplantation, or death. Results: Diet was started on the day of surgery and dialysis on the following day. Four patients had seven complications, including leakage and entanglement of the catheter in tubal fimbriae. Long-term revision-free catheter survival was 67% at 24 months. Conclusions: This minimal access technique for primary placement of peritoneal dialysis catheters includes securing of the catheter tip in a dependent location and omentectomy. It allows nearly immediate use of the catheter, leads to a minimal hospital stay, and has acceptable long-term patency.

Neonatal septum transversum diaphragmatic defects

Over 10 years, 8 infants required surgery for central diaphragmatic herniation. Contrast peritoneography and technetium-99m-sulfur colloid radionuclide scanning were the most definitive diagnostic aids. Associated anomalies included variations of the pentalogy of Cantrell. A midline gastroduodenal loop was found in two infants. Six infants are alive and well 6 months to 3 years postoperatively. An abdominal approach is preferred if there is an intestinal hernia, associated gastrointestinal anomalies, or if a bilateral defect is present.

Wandering spleen presenting as duodenal obstruction after repair of congenital diaphragmatic hernia

The most common presentation of the wandering spleen in children is torsion with infarction. Duodenal obstruction by the spleen has not been reported previously. Wandering spleen can accompany congenital diaphragmatic hernia (CDH) because of its loss of retroperitoneal fixation. If absence of normal splenic fixation is found during repair of CDH, splenopexy should be performed to eliminate the risk of torsion, infarction, or, as described here, duodenal obstruction.

External compression as initial management of giant omphaloceles

The authors describe a noninvasive technique for the management of giant omphaloceles. Two patients with giant omphaloceles were managed with external compression. Dry sterile dressings were used, buttressed by an Ace bandage in the first case and by a handcrafted Velcro abdominal binder in the second. The binder was tightened every 2 or 3 days. Renal, cardiovascular, respiratory, and gastrointestinal parameters were measured regularly to determine whether the binder was too tight. The first patient had only occasional emesis, and the defect was repaired after 40 days of compression. The second patient experienced intermittent hypertension, occasional emesis, and mild oxygen desaturation, which resolved when the binder was loosened slightly. The fascia muscle and skin were closed after 30 days of external compression. Both patients are currently living at home and doing well. This form of external compression is an effective, inexpensive, and low-risk method for the gradual reduction of giant omphaloceles, and should be considered for patients born with this problem.

Ureteral valves in children

OBJECTIVES Congenital ureteral valves are a rare cause of ureteral obstruction in children, with only 42 cases having been reported in peer-reviewed literature. Eight additional cases of ureteral valves are herein reported. METHODS We report on the diagnosis and management of eight children with ureteral obstruction secondary to a ureteral valve. RESULTS Eight children with congenital ureteral valves were managed by ipsilateral ureteroureterostomy, ureteropyelostomy, or longitudinal ureterotomy with excision of valve leaflets. The obstruction was relieved in all. CONCLUSIONS Ureteral valves should be included in the differential diagnosis of ureteral obstruction in children. Reconstruction is curative.

Child abuse as a cause of traumatic chylothorax

Chylothorax is an uncommon condition that may be associated with significant morbidity and mortality. The authors report a case of traumatic chylothorax attributed to child abuse and describe our management with tube thoracostomy and nutritional support with medium-chain triglycerides. Child abuse should be suspected in any case of chylothorax when no other etiology is evident and particularly when other signs of abuse are present.

Prolapsed hyperplastic gastric polyp causing gastric outlet obstruction, hypergastrinemia, and hematemesis in an infant

An infant presented with hematemesis and gastric outlet obstruction. Preoperative diagnosis of duodenal duplication cyst was based on a collaboration of radiological studies. At exploration the patient was found to have a gastric polyp that had intussuscepted into the duodenum leading to obstruction and hypergastrinemia secondary to gastric mucosa in the duodenal alkaline environment.