J. Schleef

Experience with gastro-intestinal duplications in childhood.

Abstract. Background: Intestinal duplications are rare congenital malformations. The different locations and sizes of these duplications require a specific diagnostic and surgical approach. This study reviews our paediatric patients with intestinal duplications in order to analyse the influence of prenatal sonography and laparoscopy on the clinical course. Patients and methods: Thirteen duplications of the alimentary tract in 12 patients have been treated over a 10-year period from 1989 to 1999. Six of our patients were diagnosed prenatally by ultrasound and were free of symptoms until surgery, except for one patient who had meconium-ileus owing to cystic fibrosis. In another five patients, the diagnosis was made on the basis of symptoms with signs of obstruction. In one child, the duplication was found incidentally during an operation for an anorectal malformation. The location of the 13 duplications was the stomach in three cases, the duodenum in one case, the jejunum in two cases, the ileum in six cases and the rectum in one case. Laparotomy was performed in ten patients. Two cases were treated by laparoscopic-assisted resection. Conclusion: Early diagnosis and treatment of uncomplicated intestinal duplications by means of prenatal sonographic screening and laparoscopic-assisted resection, respectively, are desirable in this congenital malformation. Resection of the duplication with or without minimal resection of the adjacent normal intestine should be mandatory.

Surgical correction of pectus excavatum: the Münster experience.

Objectives: Pectus excavatum is the most common congenital hereditary chest-wall deformity. This study analyses a single-center experience of pectus excavatum– thoracic wall reconstruction using a uniform technique of internal stabilization employing stainless steel struts. Methods: From June 1984 to December 1997, we performed correction operations on 777 patients with pectus excavatum. The condition occurred more frequently in boys (621 patients) than girls (156 patients). Surgical repair was performed using a standard method of double bilateral chondrotomy parasternally and at points of transition to normal ribs. This was followed by detorsion of the sternum, retrosternal mobilization and correction of the inverted ribs. The anteriorly displaced sternum was stabilized by one trans-sternal and two bilateral parasternal metal struts. Results: The corrections were completed with successful repair in 765 pati-ents (98.5%) with a low complication rate of 6.7%. The follow-up period ranged from 4 weeks to 12 years, mean 6.4 years. Major recurrences were observed in 12 patients (1.5%) and mild recurrence were observed in 35 patients (4.5%). Conclusion: Significant reduction in postoperative cardiorespiratory disorders, low lethality, improvement of subjective complaints, satisfactory long-term results and improvement in psychological problems indicate the need to offer this method of surgical correction to low-risk children.

The use of a hand-held metal detector for localisation of ingested metallic foreign bodies: a critical investigation

Ingested metallic foreign bodies (MFBs) are usually diagnosed by taking X-ray films of the neck, chest and/or abdomen. This study evaluates the use of a hand-held metal detector (HHMD) for the diagnosis and localisation of MFBs. In a prospective study, 53 consecutive paediatric patients with history of a swallowed MFB were examined with X-rays and HHMD. In 47 children, the MFB could be verified radiologically. Coins were most frequently swallowed. The HHMD could detect and locate all coins but only 47% of other MFBs. There were no false-positive results. A HHMD is an effective tool for screening the location of suspected ingested coins. This method is easy, inexpensive and free of radiation. Very small MFBs cannot be reliably detected. Conclusion:if an innocuous metallic foreign body is clearly identified with a hand-held metal detector in the stomach or lower gastrointestinal tract of an asymptomatic child, additional radiological confirmation is not required.

An easy method for laparoscopic-assisted percutaneous anterior gastropexy

Laparoscopic antireflux surgery is becoming a standard procedure in pediatric surgery. Anterior gastropexy is often performed in antireflux procedures, as well as in children with recurrent and intermittent volvulus of the stomach. We present a simple and secure technique for anterior laparoscopic-assisted gastropexy.

Ventriculopleural shunt: thoracoscopic placement of the distal catheter

Ventriculopleural shunting is usually reserved for patients with limited options for shunt revisions. We report the case of a 16-year-old boy with posthemorrhagic hydrocephalus who required numerous shunt procedures. At the age of 6 years, a ventriculopleural shunt was inserted by an intercostal thoracotomy, and 4 years later replacement of the distal catheter was necessary. Recently, he presented again with a shunt malfunction due to migration of the pleural catheter. We describe a technique for performing the placement of the distal catheter under direct thoracoscopic vision by a peel-off needle into the unscarred thoracic cavity despite two previous pleural procedures. The postoperative course was uneventful. Thoracoscopic assistance in ventriculopleural shunt placement appears to be a safe and effective technique, offering several advantages over the open procedure: it is less invasive, allows a precise positioning of the thoracic catheter under visual control, and confirms appropriate function.

Zwerchfellrekonstruktion mit verschiedenen Materialien

The relative merits of three methods of diaphragmatic hernia repair were evaluated in animals. Eighty Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other three groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized Dura, in 20 with polytetrafluoroethylene (PTFE) and in another 20 with absorbable serosa from a cow. Seventy-two animals survived the operation; they were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months. The EMG showed normal function for the absorbable material. Only scanty physiological waves were registered in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations amount to strong foreign body reactions with Dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively. It is concluded that bovine serosa can be recommended for diaphragmatic hernia.ZusammenfassungBisher gebräuchliche allogene Implantate zum Zwerchfellersatz waren mit dem Nachteil der nicht oder nur schwer verzögerten Resorbierbarkeit behaftet. Hieraus ergab sich eine hohe Rate an Thoraxfehlbildungen als auch eine nicht geringe Zahl von Rezidiven. Demgegenüber ist die Muskellappenplastik nach Hecker (M. abdominis obliqus internus and transversus) mit dem Risiko einer Bauchwandhernie and einer verlängerten Operationszeit behaftet. In einer tierexperimentellen Studie an 80 Ratten haben wir lyophilisierte Dura, PTFE mit vollresorbierbarer Rinderserosa verglichen. Als Kontrollgruppe ist eine primary fortlaufende Prolenenaht durchgeführt worden. In Äthernarkose sind nach medianer Laparotomie zunächst Resektionen des linken Zwerchfells bis auf einen schmalen Randwall vorgenommen worden. Die Untersuchungen beinhalteten EMG-Ableitungen nach 3 und 6 Monaten, physikalische Tests (Dehnbarkeit and Maximalbelastbarkeit) und histologische Untersuchungen. Die EMG-Ableitungen zeigten einen physiologischen Erregungsablauf für das vollresorbierbare Material, demgegenüber ließen sich nur rudimentdre Erregungsabläufe in der PTFE-Gruppe nachweisen. Von den physikalischen Ergebnissen her sind alle getesteten Matrialien als Zwerchfellersatz geeignet. Die histologischen Untersuchungen zeigten erhebliche Fremdkörperreaktionen für die Duraund PTFE-Implantate. Schon nach 3 Monaten post operationem war die ursprüngliche Rinderserosa nicht mehr nachweisbar. Nach unseren Ergebnissen ist ein vollresorbierbares Material als Zwerchfellersatzmaterial im Tierexperiment geeignet.The relative merits of three methods of diaphragmatic hernia repair were evaluated in animals. Eighty Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other three groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized Dura, in 20 with polytetrafluoroethylene (PTFE) and in another 20 with absorbable serosa from a cow. Seventy-two animals survived the operation; they were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months. The EMG showed normal function for the absorbable material. Only scanty physiological waves were registered in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations amount to strong foreign body reactions with Dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively. It is concluded that bovine serosa can be recommended for diaphragmatic hernia.

Short-term absorbable material for diaphragmatic replacement.

Abstract To evaluate absorbable materials for use for replacement of the diaphragm, we implanted materials in experimentally-created diaphragmatic defects in pigs. As a short-term absorbable material, bovine serosa (BS) was used. Its absorption was complete after 4–6 weeks. In a control group, the defect was repaired with a continuous running polypropylene suture. In two other groups the defect was closed with lyophilized dura (LD) and a modified transverse abdominal muscle flap according to Hecker, respectively. Physical studies (load capacity and elasticity) and histologic investigations were performed in one-half of the animals of each group after 3 and 6 months, respectively. Considering their physical properties, it could be shown that all materials tested are suitable for replacement of the diaphragm, but that BS best resembled native diaphragm. We conclude that short-term absorbable BS is suitable for replacement of the diaphragm in pigs.

Inzidenz von kontralateralen Leistenhernien im Säuglings- und Kindesalter

Inguinal hernia is a frequent surgical disease during infancy, occuring in 1 to 2% of all mature newborns and rise up to 30% of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia occured during the first two months of life, a contralateral hernia developed later highly significant (p>0.0001). Within the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral hernia in all children younger than two months.ZusammenfassungDie Inzidenz von Leistenhernien im Kindesalter beträgt 1–2%, bei Frühgeborenen steigt sie bis auf 30% an. In 9,5% der Fälle ist nach unilateraler Hernienversorgung mit der Ausbildung einer kontralateralen Hernie zu rechnen. Bei den eigenen Patienten bildete sich bei 96 Kindern (5,6%) eine kontralaterale Hernie aus. Signifikante Unterschiede bestanden hinsichtlich des Geschlechts. Jungen sind häufiger von der Ausbildung einer kontralateralen Hernie betroffen als Mädchen. War eine Hernie in den ersten 2 Lebensmonaten aufgetreten, so mußte im späteren Leben hochsignifikant mit dem Auftreten einer kontralateralen Hernie gerechnet werden (p>0,0001). Diese tritt in 84,9% der Fälle innerhalb der beiden ersten postoperativen Jahre auf. Daher halten wir die routinemäßige Simultanoperation der kontralateralen Seite bei Kindern <2 Monaten für indiziert.

Complications of Antireflux Surgery

Gastroesophageal reflux (GER) is a common finding in children of all age groups. The treatment can be conservative and surgical. In the last decade, minimally invasive approaches became very popular, and the number of surgeons performing endosurgical procedures for GER is constantly rising. GER is a very complex pathology with different aspects influencing the course of the disease and also complications resulting from surgery. The indications for surgery are fairly well described and appear to be clear. However, every patient must of course be regarded as an individual, and the treatment should be adjusted according to individual patient-related symptoms and findings.