Danny C. Little

Early repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation

BACKGROUND Timing of repair of congenital diaphragmatic hernia (CDH) in babies that require stabilization on extracorporeal membrane oxygenation (ECMO) remains controversial. Although many centers delay operation until physiologic stabilization has occurred or ECMO is no longer needed, we repair soon after ECMO has been initiated. The purpose of this study is to determine if our approach has achieved acceptable morbidity and mortality. METHODS Charts of live-born babies with CDH treated at our institution between 1993 and 2007 were retrospectively reviewed. Data were then compared with The Congenital Diaphragmatic Hernia Study Group and Extracorporeal Life Support Organization registries. RESULTS Forty-eight (39%) patients required ECMO Thirty-four of these 48 neonates were cannulated before operative repair. Venoarterial ECMO was used exclusively. The mean (SD) time of repair from cannulation was 55 (21) hours. Survival for this subset of patients was 71%. Three patients (8.8%) who underwent repair on ECMO experienced surgical site hemorrhage that required intervention. CONCLUSION Early repair of CDH in neonates on ECMO can be accomplished with acceptable rates of morbidity and mortality.

Laparoscopic Cholecystectomy in Obese and Non-Obese Children

BACKGROUND Obesity is an increasing problem in the pediatric population. Despite abundant data on the impact of obesity in adults, little data exist that examines the impact of obesity on surgical outcomes in children. We reviewed our experience with laparoscopic cholecystectomy to evaluate the impact of obesity. METHODS We performed a retrospective chart review of patients who underwent laparoscopic cholecystectomy between September, 2000 and June, 2009. Demographics, indication, length of operation, length of stay, and complications were examined. Body mass index (BMI) was calculated and BMI percentage according to gender and age was determined. RESULTS There were 312 patients identified, 150 patients were normal weight (BMI less than 85%), 65 patients were overweight (BMI = 85%-95%), and 97 patients were obese (BMI > 95%). The mean age of the patients was 14 y (range 0-20), and 76% were female. The overweight and obese groups had more females (P = 0.022 and P = 0.0016) and the obese group was older (P = 0.0003). No differences were found between the groups in the indication for cholecystectomy. There was no difference in operative time, length of stay, or complications between normal weight patients and overweight or obese patients. CONCLUSION Despite the known surgical challenges with overweight patients, laparoscopic cholecystectomy is a safe and equally beneficial procedure in overweight children.

Diminishing role of contrast enema in simple meconium ileus.

PURPOSE Contrast enema is the initial study of choice for simple meconium ileus to confirm diagnosis and to relieve obstruction. Despite favorable historically published results, our clinical impression suggests decreased effectiveness of the contrast enema resulting in more surgical interventions in contemporary practice. METHODS A retrospective multiinstitutional review for a 12-year period was conducted for neonates diagnosed with meconium ileus by contrast enema. The neonates were divided into 2 groups-historic group (HG = before 2002) and contemporary group (CG = after 2002). T test was used for comparison of continuous variables and chi(2) for categorical data. RESULTS Thirty-seven total patients were identified (21 females and 16 males). Obstruction was relieved in 8 neonates (22% overall success rate). Average enema attempt per patient was decreased in the CG group compared to HG (1.4 vs 1.9). The success rate in the CG group was 5.5% (1/18) compared to 39% (7/18) in HG. CONCLUSIONS In this review, success of contrast enema for relief of meconium ileus has significantly decreased over time. These findings may be because of reluctance to repeat enemas, change in radiologist experience, or use of contrast agent. As a result, higher rates of operative intervention are now observed. In stable patients, surgeons should recommend repeat enemas before exploration.

Should We Be Concerned About Jejunoileal Atresia During Repair of Duodenal Atresia

INTRODUCTION During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population. METHODS After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded. RESULTS Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair. CONCLUSIONS In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.

Return of the surgeon in the diagnosis of pyloric stenosis

BACKGROUND The diagnosis of pyloric stenosis (PS) by physical examination is a lost art that has been replaced by radiology-performed ultrasound (US). The purpose of this study is to demonstrate that the diagnosis of PS can be made solely upon the surgeons US evaluation. METHODS Surgical ultrasonographers included 2 senior general surgery residents and 2 pediatric surgery residents without prior formal US experience. These surgeons underwent proctored training in the use of US for PS. Measurements including channel length and muscle thickness were recorded at bedside. A positive examination included muscle thickness more than 4 mm and channel length more than 16 mm. Patients with positive results underwent pyloromyotomy. Negative results were confirmed with a repeat US through the radiology department, and infants without PS were subsequently referred for appropriate medical management. RESULTS Thirty-two consecutive patients with suspected PS were evaluated using surgeon-performed ultrasonography. All examinations were diagnostically accurate. There were no false-positive or false-negative result. Seven patients (22%) were correctly determined to be negative for PS. The remaining 25 infants underwent successful pyloromyotomy with resolution of symptoms. CONCLUSION Surgeons who have undergone focused training to perform US for PS can diagnose the condition without confirmatory testing by a radiologist.