Daniel J. Ostlie

Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis: A Prospective, Randomized Trial

Background:Pyloric stenosis, the most common surgical condition of infants, is treated by longitudinal myotomy of the pylorus. Comparative studies to date between open and laparoscopic pyloromyotomy have been retrospective and report conflicting results. To scientifically compare the 2 techniques, we conducted the first large prospective, randomized trial between the 2 approaches. Methods:After obtaining IRB approval, subjects with ultrasound-proven pyloric stenosis were randomized to either open or laparoscopic pyloromyotomy. Postoperative pain management, feeding schedule, and discharge criteria were identical for both groups. Operating time, postoperative emesis, analgesia requirements, time to full feeding, length of hospitalization after operation, and complications were compared. Results:From April 2003 through March 2006, 200 patients were enrolled in the study. There were no significant differences in operating time, time to full feeding, or length of stay. There were significantly fewer number of emesis episodes and doses of analgesia given in the laparoscopic group. One mucosal perforation and one incisional hernia occurred in the open group. Late in the study, 1 patient in the laparoscopic group was converted to the open operation. A wound infection occurred in 4 of the open patients compared with 2 of the laparoscopic patients (P = 0.68). Conclusions:There is no difference in operating time or length of recovery between open and laparoscopic pyloromyotomy. However, the laparoscopic approach results in less postoperative pain and reduced postoperative emesis. In addition, there was a fewer number of complications in the laparoscopic group. Finally, patients approached laparoscopically will likely display superior cosmetic outcomes with long-term follow-up.

The use of laparoscopy in the management of nonpalpable undescended testes.

Purpose of review The stable incidence of undescended nonpalpable testes and the ever-progressing utilization of laparoscopy has led to the commonplace utilization of laparoscopy in the diagnosis and treatment of these nonpalpable testes. The historical published literature is ambiguous with regard to recommendations regarding the use of laparoscopy in the setting of nonpalpable testes. As a result, this review is timely and necessary in that it is important for the practicing physician and surgeon to review and have available to them the current recommendations for the management of patients with nonpalpable testes. Recent findings With ongoing advances of minimally invasive surgery in the face of the limitations of both ultrasound and magnetic resonance imaging, the use of laparoscopy in the diagnosis and treatment of nonpalpable testes is now commonplace. Several reports recommend laparoscopy as the gold standard for the evaluation and treatment of nonpalpable testes, allowing for localization of the testis, characterization of the testis and associated structures (vas deferens, testicular vessels) and subsequent treatment options. Summary Because of the superior diagnostic capabilities and the ability to provide therapeutic interventions, laparoscopy should be used in the evaluation and treatment of all patients with nonpalpable testes.

Laparoscopic management of intussusception in pediatric patients.

INTRODUCTIONnMinimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. Successful laparoscopic reduction has been demonstrated, but the utility of laparoscopy, for more complex cases, is less well documented. Therefore, we reviewed our experience with laparoscopy in patients with radiographically irreducible intussusception to document the safety and effectiveness of this approach.nnnMETHODSnWe conducted a retrospective review of all of the patients who had a radiographically irreducible intussusception treated via the laparoscopic approach at a single institution from 1998 to 2008. Means are expressed +/- standard deviation.nnnRESULTSnA total of 22 patients were identified, with an average age of 2.9 +/- 3.0 years. Average length of stay was 2.67 +/- 1.5 days (median, 2). Sixteen (73%) of the 22 patients were male. There were 19 ileocecal and 3 small bowel intussusceptions. Twenty patients (91%) were able to be managed entirely laparoscopically or via extension of the umbilical incision, while 2 necessitated conversion, using a right-lower quadrant incision. Nine patients had an extension of the umbilical incision; 7 of these underwent a bowel resection. Ten patients (46%) had a bowel resection, of which 5 were an ileocecectomy and 5 were segmental small bowel resection. There were a total of 9 patients with a pathologic lead point, 5 patients with lymphoid hyperplasia, and 4 with Meckels diverticula.nnnCONCLUSIONnWe conclude that laparoscopy is a reasonable approach to pediatric intussusception, even in the event when bowel resection is necessary.

Laparoscopic ileocecectomy in pediatric patients with Crohn's disease.

INTRODUCTIONnDefinitive management for medically refractory ileocecal Crohns disease is resection with primary anastomosis. Laparoscopic resection has been demonstrated to be effective in adults. There is a relative paucity of data in the pediatric population. We therefore audited our experience with laparoscopic ileocecectomy in patients with medically refractory ileocecal Crohns disease to determine its efficacy.nnnMETHODSnWe conducted a retrospective review of all pediatric patients who underwent laparoscopic ileocecal resection for medically refractory Crohns disease at a single institution from 2000 to 2009.nnnRESULTSnThirty patients aged 10-18 years (mean: 15.3 years) with a mean weight of 50u2009kg (standard deviation:u2009±u200915.5u2009kg) underwent laparoscopic ileocecectomy for Crohns disease. Five of these were performed using a single-incision laparoscopic approach. The indications for surgery were obstruction/stricture (21), pain (10), abscess (3), fistula (3), perforation (2), and bleeding (1). Some patients had multiple indications. There were a total of five abscesses encountered at operation. Eight patients were on total parenteral nutrition at the time of resection. Twenty-five patients (83.3%) were being treated with steroids at operation. The anastomosis was stapled in 26 patients and hand-sewn in 4. Two patients developed a postoperative abscess, and both of them were taking 20u2009mg of prednisone daily. One patient developed a small bowel obstruction due to a second Crohns stricture that manifested itself after the more severe downstream obstruction was relieved with ileocecectomy. Of the 5 patients who underwent a single-incision laparoscopic operation, 3 underwent for obstruction/stricture and 2 for perforation. There were no intraoperative or postoperative complications. The patients were followed up for a maximum of 80.7 months (average: 14.7 months; median: 9.7 months). There were no anastomotic leaks or wound infections.nnnDISCUSSIONnThis series demonstrates that laparoscopic ileocecectomy, both single-incision laparoscopic approach and standard laparoscopy, is safe and effective in the setting of medically refractory Crohns disease in pediatric patients.

Pyloric stenosis: from a retrospective analysis to a prospective clinical trial - the impact on surgical outcomes.

Purpose of review Pyloric stenosis is the most common surgical condition of infants. The operative approach, however, is currently debated in the literature following the application of laparoscopic and circumumbilical techniques to facilitate the pyloromyotomy. In this review, we will examine the published data and critically evaluate the influence of prospective data in delineating truths and illuminating flaws of retrospective data on a controversial topic. Recent findings Retrospective data are highly discordant on the influence an operative approach for pyloromyotomy has on operating time, time to goal feeds, length of stay and complications. Prospective randomized data demonstrate that when the postoperative management is controlled, the approach does not influence length of recovery in a clinically relevant manner. Prospective data also demonstrate that the operating time can be the same for the laparoscopic and open approaches with no differences in complications for centers with good laparoscopic volume. There are no prospective data to contrast the circumumbilical approach with the other approaches; however there is an inherent and obvious cosmetic advantage to the laparoscopic and circumumbilical approaches, which avoid a large epigastric incision. Summary The laparoscopic approach does not appear to influence length of recovery compared to the open operation. Prospective data show the laparoscopic approach results in less postoperative pain and can be done with no increase in operating time or complications.

PAPS PapersFollow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

OBJECTIVEnCurrent APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation.nnnMETHODSnFollowing IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III.nnnRESULTSnBetween 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3±4.8 years and 40.1±19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7±1.0 and mean bedrest was 1.6±0.6 days, resulting in 2.5±1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5±1.0 and mean bedrest was 1.6±0.6 days, resulting in 1.7±0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury.nnnCONCLUSIONSnThese data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.

Impact of Body Habitus on Single-Site Laparoscopic Appendectomy for Nonperforated Appendicitis: Subset Analysis from a Prospective, Randomized Trial

INTRODUCTIONnThere have been several series documenting the utility of single-site laparoscopic appendectomy. However, there are no data to support patient selection based on their physical characteristics. We recently completed a large prospective, randomized trial comparing single-site laparoscopic appendectomy with standard three-port laparoscopic appendectomy for nonperforated appendicitis. This dataset was used to examine the relative impact of body habitus on operative approach.nnnSUBJECTS AND METHODSnWe performed an analysis of the dataset collected in a prospective, randomized trial of 360 appendectomy patients who presented with nonperforated appendicitis. Body mass index (BMI) was calculated and plotted on a growth chart to obtain BMI percentile according to gender and age. Standard definitions for overweight (BMI 85-95%) and obesity (BMI >95%) were used.nnnRESULTSnIn the single-site group there were 26 overweight and 19 obese patients. In the three-port group there were 25 overweight and 16 obese patients. There were no significant differences between overweight and normal with either approach. However, with the single-site approach there was longer mean operative time, more doses of postoperative narcotics given, longer length of stay, and greater hospital charges in obese patients. In the three-port group, there were no differences between normal and obese patients.nnnCONCLUSIONSnWhen using the single-site approach for appendectomy, obesity in children creates longer operative times, more doses of postoperative analgesics, longer length of stay, and greater charges. However, obesity has no impact on three-port appendectomy.

The safety of laparoscopy in pediatric patients with ventriculoperitoneal shunts.

INTRODUCTIONnIn pediatric patients requiring abdominal operations, ventriculoperitoneal (VP) shunts for hydrocephalus are a frequently encountered comorbidity. Laparoscopy has not been extensively evaluated in this population, and there are concerns about the safety of insufflation under pressure with the shunt in place. There are a paucity of data in the literature to address this issue. Further, there is a relative lack of long-term follow-up in the literature to document shunt function over time after abdominal procedures. Therefore, we reviewed our experience in patients with VP shunts who underwent either open or laparoscopic abdominal procedures to determine the safety of laparoscopy in these patients.nnnMETHODSnWe conducted a retrospective review of all pediatric patients with VP shunts who underwent laparoscopic and/or open abdominal operations at a single institution from 1998 to 2008. Complications were defined as a shunt- or surgery-related event (including any shunt revisions) within 6 months of abdominal surgery. Continuous variables were compared by using an independent sampled, two-tailed Students t-test. Discrete variables were analyzed with Fishers exact test with Yates correction, where appropriate. Significance was defined as P < or = 0.05.nnnRESULTSnA total of 99 intra-abdominal operations were performed on patients with VP shunts: 51 were laparoscopic and 48 were open. Mean age was 3.17 versus 2.93 years, respectively (P = 0.77). The most common procedure performed in both groups was fundoplication with gastrostomy. There were no episodes of air embolism into the shunt. There was 1 shunt infection in the laparoscopic group and 3 in the open group (P = 0.56).nnnCONCLUSIONSnOur data suggest that laparoscopy is safe in patients with ventriculoperitoneal shunts.

Laparoscopic Management of Small Bowel Obstruction in Children

INTRODUCTIONnThe use of laparoscopy in the treatment of acute small bowel obstruction (SBO) faces inherent obstacles, including dilated loops of bowel, a limited working space, and postoperative adhesions. The objective of this study was to outline the efficacy of laparoscopic management of SBO in children.nnnMETHODSnWith Institutional Review Board (IRB) approval, children who presented with a diagnosis of SBO and underwent management via a laparoscopic approach at our institution from January 2001 to December 2008 were retrospectively reviewed. Medical records were reviewed for age, weight, etiology of obstruction, radiographic findings, need for conversion, number of operations, length of stay, and postoperative complications. Statistical analyses of data comparison between those patients who were managed utilizing a laparoscopic approach and those in whom the laparoscopic approach was converted to a laparotomy were performed using a Chi-squared or a two-tailed Students t-test with significance reported for Pu2009<u20090.05.nnnRESULTSnThirty-four patients underwent laparoscopic management of SBO. Mean age was 8.1u2009±u20095.9 years with a mean weight of 32.8u2009±u200924.6u2009kg. Sixty-seven percent were male. A preoperative computed tomography scan was obtained in 21 patients (62%). Eleven cases (32%) required conversion to laparotomy. The most common reason for conversion to the open approach was poor working space (45.4%) followed by intestinal volvulus (27.2%), inability to identify source of obstruction (18.2%), and enterotomy (9%). The most common cause of SBO was postoperative adhesions (73.5%), followed by Meckels diverticulum (8.8%), volvulus (8.8%), and other (8.8%). Postoperative complications occurred in 5 patients (14.7%). One patient died within 30 days of exploration due to intestinal ischemia secondary to midgut volvulus and subsequent septic shock. Five patients (14.7%) had a recurrent SBO with a mean time to recurrence of 2.6u2009±u20092.1 months. There were no significant differences in demographic or preoperative variables between patients who were successfully managed with laparoscopy alone versus those patients in whom conversion to laparotomy was necessary. In patients who required conversion, the laparoscopic evaluation did aid in identifying the etiology and allowed for a directed surgical approach when appropriate.nnnCONCLUSIONSnLaparoscopy for the management of SBO in children is safe and can be therapeutic in the majority of patients. We recommend that consideration for initial exploration in children with SBO be carried out via the laparoscopic approach, with an understanding that conversion to an open approach may be necessary to complete the operation.

Influence of Histamine Receptor Antagonists on the Outcome of Perforated Appendicitis Analysis From a Prospective Trial

HYPOTHESISnDiphenhydramine blocks the H(1) receptor to treat pruritus or to induce sleep, while ranitidine blocks the H(2) receptor to suppress gastric acid. They are often given to ill patients, such as those with perforated appendicitis. However, these receptors are integral to the inflammatory response, and to our knowledge, the impact of H(1) or H(2) blockade on outcome in the setting of perforated appendicitis has never been evaluated.nnnDESIGNnProspective randomized trial.nnnSETTINGnReferral center.nnnPATIENTSnChildren undergoing an operation for perforated appendicitis from April 2005 to November 2006.nnnMAIN OUTCOME MEASURESnWe conducted multivariate analysis with Pearson correlation on data from a prospective randomized trial comparing antibiotic regimen after appendectomy for perforated appendicitis and outcome. Medications with a significant correlation to abscess development were investigated by comparing those receiving the medication with those who did not using the t test for continuous variables and chi(2) test for discrete variables. Significance was defined as P < or = .05.nnnRESULTSnSignificant correlations were found between the use of ranitidine (P = .05) or diphenhydramine (P = .03) and the development of an abscess. Direct comparison found no differences in patient or operative variables in those given either medication compared with those receiving no doses. Abscess rate in those receiving neither medication (n = 41) was 10%. Those given only ranitidine (n = 24) or diphenhydramine (n = 17) had doubled abscess rates of 17% and 18%, respectively. Those given both medications (n = 16) had a quadrupled abscess rate of 44% (P = .03).nnnCONCLUSIONSnRanitidine or diphenhydramine given to patients with perforated appendicitis may increase the risk of postoperative abscess. Therefore, these medications should not be used empirically in this population.