David Terence Thomas

Perioperative Anesthetic and Surgical Complications of the Nuss Procedure

OBJECTIVE The Nuss procedure is a chest wall remodeling surgery performed in patients with pectus excavatum. This study was performed to analyze perioperative surgical and anesthetic complications with the Nuss procedures. DESIGN A retrospective analysis. SETTING An academic hospital. PARTICIPANTS Two hundred fourteen patients (children, adolescents, and adults) undergoing the Nuss procedure over 6 years. INTERVENTIONS Patient age and sex, premorbid diseases, indications for surgery, patient position during the procedure, the length of surgery, time to hospital discharge, postoperative analgesia method, and the presence of perioperative complications were recorded. MEASUREMENTS No mortality was observed. The overall complication rate was 18.7%, but the overall event rate was 42.6% (91 events in 40 patients). Intraoperative hypotension, tachycardia, and hypercapnia were the most common complications (4.7%), followed by postoperative ileus (3.2%), pneumothorax (right, left, or bilateral; 4.2%), lung parenchymal laceration (2.3%), and postoperative nausea and vomiting (2.3%). Two patients had an ulnar nerve palsy and 1 patient had a brachial nerve palsy as a result of surgical position. CONCLUSION Although the Nuss procedure is reported to be minimally invasive, some serious complications concerning both surgery and anesthesia should not be overlooked.

The Effect of Untethering on Urologic Symptoms and Urodynamic Parameters in Children With Primary Tethered Cord Syndrome

OBJECTIVE To evaluate urinary system symptoms (USSs) and urodynamic parameters (UPs) before and after untethering in children with primary tethered cord syndrome (pTCS). METHODS USSs and UPs of patients undergoing untethering for pTCS during the period January 2008-July 2012 were evaluated preoperatively and at the postoperative third and 12th months. For analysis, patients were separated into 4 groups according to the presence of USSs: group 1, USSs preoperative positive and postoperative negative; group 2, USSs preoperative positive and postoperative positive; group 3, USSs preoperative negative and postoperative positive; group 4, USSs preoperative negative and postoperative negative. Preoperative and postoperative USSs and UPs were compared. RESULTS Forty patients (average age, 7.2 years, follow-up of 2.8 years) were included. There were 13 patients in group 1, 11 in group 2, 3 in group 3, and 13 in group 4. All patients showed improvement when preoperative and postoperative USSs and UPs were compared. There was no correlation between USSs and UPs, both preoperatively and postoperatively. USSs and UPs at the postoperative third and 12th months were similar. Patients with no USS showed the most significant improvement in UP after untethering. CONCLUSION Our study has demonstrated that untethering in patients with pTCS improves urologic symptoms and UPs. However, there is no correlation between improvement in symptoms and urodynamic findings. Urodynamic changes are similar at the postoperative third and 12th months. As the most significant improvement was seen in patients without USSs, it is important that these patients undergo urodynamic studies preoperatively and postoperatively.

Horner's Syndrome as a rare complication of tube thoracostomy: Case reports and review of literature

Horners Syndrome (HS), caused by the interruption of the oculosympathetic pathway, is a rare yet morbid complication of tube thoracostomy. However, literature regarding HS secondary to tube thoracostomy is limited to case reports, with little comprehensive information available. We report two cases and review all cases from the published literature to assess the outcome of this complication. HS secondary to tube thoracostomy leaves sequelae in 45.8% of patients. Immediate removal or repositioning of the tube does not affect prognosis. Therefore, precautions must be taken to avoid this complication.

The effect of dorsal dartos flaps on complication rates in hypospadias repair: A randomised prospective study

AIM This study prospectively analysed the effect of using a dartos flap on the complication rates of TIPU (tubularised incised plate urethroplasty) in hypospadias repair. MATERIAL AND METHODS Patients having TIPU repair for hypospadias at our university hospital between January 2010 and August 2013 were prospectively divided into two groups. Group 1 had TIPU repair with dorsal dartos flap, whereas group 2 had flapless repair. At the end of the follow-up period (mean 23.3 m, median 20.2), complication rates were compared between two groups. RESULTS There were 107 patients in each group. The overall complication rate was 9.3%. The complication rates were 12.1% in group 1 (6 glans dehiscence and 7 fistula) and 6.5% in group 2 (2 glans dehiscence and 5 fistula). The differences between complication rates and fistula were statistically insignificant (p = 0.2511 and p = 0.7710, respectively). CONCLUSION Our prospective and randomised study found that the use of dartos flaps in hypospadias offers no statistically significant advantage over flapless repair for complication rates.

Does common channel length affect surgical choice in female congenital adrenal hyperplasia patients

OBJECTIVE Partial/total urogenital sinus mobilization (UGSM) is one of the recommended techniques for treatment of female congenital adrenal hyperplasia (CAH). In this study we compared the length of common channel (CC) and type of operation performed in CAH patients. PATIENTS AND METHODS We retrospectively analyzed data of patients receiving surgery for female CAH. Patients were separated into three groups: group 1 had partial UGSM, group 2 had total UGSM, and group 3 had total UGSM plus the vaginal anterior wall was made from CC. Age at surgery, length of CC, surgical time, follow-up time, and complications were compared. RESULTS There were a total of 29 patients. For groups 1, 2, and 3, the average age at surgery was 47.2 months, 14.4 months, and 21.3 months, respectively, and the average CC length was 1.25 cm, 3.1 cm, 4.3 cm, respectively. The average time of surgery was 165 min, 193.1 min, 282.5 min, respectively. The average follow-up time was 34.7 months, 36.3 months, 28.3 months, respectively. There were two complications (UGS flap necrosis and opening of sutures) in the third group. CONCLUSION We advise the use of partial UGSM for CC of 0.5-2 cm, total UGSM for CC of 2.5-3.5 cm, and total USM with use of CC as the anterior vaginal wall in CC ≥ 4 cm in length. Good cosmetic and functional results are obtained with this approach.

Should we routinely test for chordee in patients with distal hypospadias

OBJECTIVES The aim of this study was to determine the incidence of chordee in distal hypospadias and compare our intraoperative findings with those reported by the families of patients and to determine if routine testing for chordee should be performed in patients with distal hypospadias. MATERIAL AND METHODS Surgical reports and medical files of distal hypospadias patients operated from January 2008 to January 2013 were prospectively reviewed. The type of hypospadias, familys report of chordee, intraoperative finding of chordee and its degree were noted. All patients were tested for chordee intraoperatively after degloving. RESULTS A total of 156 patients of which 27 had glandular, 61 coronal, and 68 subcoronal hypospadias were included in the study. Chordee was found in 52 patients (33.3%) intraoperatively, whereas only 15 families (9.6%) reported chordee preoperatively. CONCLUSION There is risk of chordee in patients with distal hypospadias that needs to be accurately identified and corrected. Families are not always aware of the presence of chordee.

Comparison of uroflow parameters in children with pure constipation versus constipation plus lower urinary tract symptoms.

Abstract Objective: The aim of this study was to compare uroflow parameters of patients with pure constipation against those with constipation plus lower urinary tract symptoms (LUTS) and a control group (no constipation). Materials and methods: During August 2012 to March 2014 three groups of patients were enrolled into the study: group C (constipation only), group CL (LUTS plus constipation) and group N (control: no constipation or LUTS). Dysfunctional elimination syndrome (DES) scores, uroflowmetry/electromyography (uroflow-EMG) findings, postvoiding residual urine (PVR) and rectal diameter were measured and compared between groups. Results: Groups C, CL and N comprised 80, 100 and 30 patients, respectively. Average DES scores were 12.6, 18.7 and 4.9, respectively. Voided volume (as a percentage of expected bladder capacity) was 104%, 89% and 101%; and average maximum flow rate was 21.1 ml/s, 36.4 ml/s and 28.1 ml/s, respectively. Pelvic floor muscle activity during voiding was seen in 40.0%, 42.0% and 6.7% of patients in groups C, CL and N, respectively; and pathological PVR was seen in 26.3%, 55.0% and 3.3% of patients in the respective groups. Average rectal diameter was measured as 38.6 mm, 36.4 mm and 28.1 mm in groups C, CL and N, respectively. Conclusion:: This study found that abnormal voiding parameters are present in patients with constipation even if LUTS are not present. Therefore, it is important that all patients presenting with constipation have their voiding function evaluated.

Positional installation of contrast (pic) and redo-pic cystography for diagnosis of occult vesicoureteral reflux

Karadeniz-Cerit K, Thomas DT, Ergun R, Yıldız N, Alpay H, İnanır S, Dağlı ET, Tuğtepe H. Positional installation of contrast (PIC) and Redo-PIC cystography for diagnosis of occult vesicoureteral reflux. Turk J Pediatr 2018; 60: 180-187. To evaluate the value of Positional Installation of Contrast (PIC) and Redo-PIC cystography in patients with febrile recurrent urinary tract infection (f-UTI) where voiding cystourethrogram (VCUG) was negative. Patients with recurrent f-UTI with no reflux on VCUG referred to the outpatient clinic of Pediatric Urology, between June 2011 and June 2016 were included in the study. A PIC cystography was performed in all patients. When reflux was found, subureteric injection was performed. Urinary cultures were used for follow-up. Patients that continued having f-UTI, received redo-PIC cystography. PIC cystography was performed on 42 patients. The average age of patients was 8.0±3.6 years. Vesicoureteral reflux (VUR) was detected in 41 patients. Average follow-up time after PIC cystography was 44.6 months. Thirty-three patients (80.5%) were free of f-UTI after PIC cystography and concurrent subureteric injection. Eight patients continued to have recurrent f-UTI. Six of these patients underwent redo-PIC cystography and PIC-VUR was demonstrated in all patients. After an average follow up of 30.9 months, no f-UTI was seen in these patients. The success rate of 80.5% (33/41) after 1st PIC cystography and subureteric injection increased to 95.1% (39/41) after redo-PIC cystography in six patients. Patients with recurrent f-UTIs without VUR on VCUG are an important challenge. PIC cystography is an important tool in demonstrating occult VUR in these patients. We advise that PIC cystography is performed in all patients with recurrent f-UTI with negative VCUG and redo-PIC cystography in patients who continue to have f-UTI after 1st PIC cystography and subureteric injection.

Ultrasound-guided Erector Spinae Plane Block in a Child Undergoing Laparoscopic Cholecystectomy

Erector spinae plane block (ESP) is a recently described regional anesthesia technique that leads to the blockage of both visceral and somatic nerve fibers. While there are anecdotal reports of ESP used in children, none are for laparoscopic procedures. Herein we report a child undergoing laparoscopic cholecystectomy in which ESP was used as part of multimodal anesthesia. Ultrasound-guided ESP block is an easily performed peripheral nerve block that leads to long-lasting postoperative analgesia. It can be successfully used in pediatric laparoscopic procedures such as cholecystectomy and should be kept in mind as an option for multimodal analgesia in children.