Guy F. Brisseau

The respiratory advantage of laparoscopic Nissen fundoplication.

BACKGROUND/PURPOSE Laparoscopic Nissen fundoplication is replacing the open approach in the treatment of children with gastroesophageal reflux. The postoperative respiratory advantages seem obvious but remain unproven. The authors hypothesized that laparoscopic Nissen fundoplication provides postoperative respiratory advantages in neurologically normal children as well as those with mental retardation or profound neurologic impairment. METHODS The charts of all laparoscopic Nissen fundoplications over a 4-year period were reviewed. Sixty-one laparoscopic procedures were compared with the most recent 61 consecutive open Nissen fundoplications. The following variables were reviewed: age, weight, gender, preexisting comorbidities, operating time, postoperative pulmonary complications, and length of stay. Categorical data were compared for significance utilizing chi2 cross tabulation. Variables representing numerical data were compared by t test. RESULTS Although there appeared to be a trend toward sicker patients in the open group, the laparoscopic group showed significantly improved rates of extubation, shorter recovery room stays, shorter durations of chest physiotherapy, fewer intensive care unit admissions, more rapid resumption of baseline feedings, and overall decreased length of stay (P < 0.05). Pulmonary benefits also were noted in the neurologically impaired population when analyzed separately. CONCLUSIONS Laparoscopic Nissen fundoplication confers a definable benefit with a significant pulmonary advantage in both neurologically normal children and those with neurologic impairment.

Congenital pancreatic cysts in children

The authors report a case of an 11-year-old girl with a solitary, congenital pancreatic cyst and review the literature. Such cysts are very rare and typically are diagnosed in childhood. As a neonate, this patients paternal half brother also had undergone resection of a congenital pancreatic cyst. The authors believe this is the first documented familial incidence of a congenital pancreatic cyst.

Miniature Access Chait Cecostomy: A New Approach to the Management of Fecal Incontinence

The antegrade continence enema is a well-established procedure in the management of children with fecal incontinence. Chait and Shandling described the percutaneous approach for the management of these children. This procedure eliminates the need for an operation, can be performed under sedation and local anesthesia, and is clinically effective with minimal morbidity. However, it entails several important disadvantages. First, it is a blind procedure. Second, the cecum is not secured to the abdominal wall. Third, the procedure requires a skilled interventional radiologist. And fourth, it must be performed in two stages. We chose to alter the procedure by using a miniature access surgical approach. Miniature access Chait cecostomy was performed in four children with fecal incontinence. Under laparoscopic visualization, the cecum was identified, mobilized, and sutured to the anterior abdominal wall; the Chait device was then inserted. The procedure permitted excellent cecal visualization and mobilization. P...

Complication Avoidance in Miniature Access Pyloromyotomy

Miniature access pyloromyotomy is a well-established procedure for the management of infants with pyloric stenosis. Several studies comparing the miniature access and open approaches have found that the incidence of complications is similar in both. It appears that the miniature access approach offers potential benefits such as superior cosmetic results, earlier feeding, and a shorter hospital stay. We describe our complications and complication avoidance techniques for this procedure. A 2-year period was selected for the study, and 160 infants undergoing miniature access pyloromyotomy at two centers were analyzed. Complications occurred in 7 (4.38%) of the 160 cases: 2 duodenal perforations (1.25%), 2 incomplete myotomies (1.25%), 1 omental evisceration (0.62%), and 2 umbilical wound infections (1.25%). The following measures were taken to prevent complications: avoiding the umbilicus if epithelialization was inadequate, using low flow and moderate pressure carbon dioxide insufflation, careful grasp of t...

The Next Generation of Miniature Access Pyloric Spreader

Surgeons are always striving to improve miniature access surgery by developing new techniques and instruments. Based on our understanding that the original Ramstedt pyloromyotomy and the Benson pyloric spreader are time-tested for open surgery, we designed a unique miniature access pyloric spreader. The instrument, modeled after the Benson spreader, was used in eight infants with pyloric stenosis. The spreader has the following unique features: It is slim, opens with double action, is serrated on both sides, is angled, and can be used without a trocar. The use of the miniature access pyloric spreader facilitated the performance of the crucial step in the pyloromyotomy procedure. Its slim size allowed the spreader to fit easily into the myotomy incision. Serrations outside the spreader created enough friction to prevent the instrument from sliding. The double action mechanism allowed the equal distribution of force on both sides of the myotomy. Percutaneous introduction without a trocar decreased abdominal...

Laparoscopy for Small-Intestinal Bleeding in Children

Background and Purpose: The source of gastrointestinal bleeding in children is usually readily identifiable with a standard evaluation. Rarely, the source of bleeding is obscure and may be conditions such as intestinal duplication, Meckels diverticulum, or Henoch-Schonlein purpura (HSP). Laparoscopy is an ideal modality to identify such obscure sources and may also allow definitive therapy at the time of evaluation. The authors describe their experience with this modality. Patients and Methods: In a 1-year period, 64 patients were evaluated for gastrointestinal bleeding. Laparoscopy was used for diagnosis and treatment when the source of bleeding could not be ascertained by physical examination and upper or lower tract endoscopy or both. Results: Upper tract endoscopy and colonoscopy failed to demonstrate a bleeding source in four patients. The source of bleeding was a Meckels diverticulum in three patients. Two of these lesions were suspected preoperatively from Meckels scans. The source of bleeding i...