Kristine Kit Yi Pang

Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery

BACKGROUND Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population. METHODS We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique. RESULTS A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications. CONCLUSIONS Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments.

One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients' characteristics and non-invasive investigations at baseline by a cross-sectional study in a prospective cohort of 318 teenagers and young adults.

To describe a service delivery model and report the baseline characteristics of patients investigated by a non‐invasive approach for ketamine‐associated uropathy.

Socioenvironmental Factors Associated With Constipation in Hong Kong Children and Rome III Criteria

Objective: Data regarding the prevalence of constipation in the general population of Asian children using internationally standardized definitions are scarce. Environmental factors surrounding a childs day to day living may trigger or perpetuate constipation and encourage postponement of defecation. Methods: A territory-wide cross-sectional questionnaire survey was conducted in 2318 Hong Kong Chinese elementary school students. Constipation was defined by pediatric Rome III criteria. Results: The mean age of the children was 9 ± 1.9 years; 51% were boys. Two hundred eighty-two children (12.2%, 95% confidence interval [CI] 10.9%–13.5%) were found to have constipation. Children ages 6 to 7 years had the highest prevalence (16.8%, 95% CI 13.8%–19.8%). There was no difference in prevalence between boys and girls (11.6% vs 12.3%; P > 0.05) and between obese and nonobese children (11.5% vs 11.1%; P > 0.05). In univariate analysis, constipation was found to be significantly more prevalent among those children who lived with neither parent, had inadequate company of parents at home, refused to pass bowel movements in school, spent long hours doing homework, had inadequate sleep, and had decreased fiber intake and frequent consumption of fast food (P < 0.05). Multivariate analysis identified refusal to pass bowel movements in school toilets (odds ratio [OR] 1.97, 95% CI 1.42%–2.74%), having dinner with one/both parents <50% of time (OR 1.52, 95% CI 1.01%–2.31%), nighttime sleep <7 hours (OR 1.87, 95% CI 1.04%–3.33%), and frequent consumption of fast food (OR 1.14, 95% CI 1.03%–1.26%) to be independent factors associated with constipation. Conclusions: Socioenvironmental factors are associated with childhood constipation, and bringing them to the awareness of the public may help prevent or stop the progression of childhood constipation at its early stages.

Impact of pediatric Rome III criteria of functional dyspepsia on the diagnostic yield of upper endoscopy and predictors for a positive endoscopic finding.

Objective: Pediatric Rome III criteria of functional dyspepsia (FD) has eliminated the mandatory use of upper endoscopy and recommended a symptom-based approach. In the absence of alarm symptoms, FD can be positively diagnosed in children having normal physical findings without exclusionary investigations. We aimed to investigate the effectiveness of Rome III guidelines to discriminate organic diseases from FD and to identify the predictors for positive endoscopic findings. Patients and Methods: A prospective study was conducted on consecutive children fulfilling Rome III criteria of FD. Upper endoscopy was performed in all subjects, both with and without alarm features. Results: Eighty consecutive children ages 7 to 15 were recruited. Nine (11.3%) had experienced alarm features. Five (6.3%) had organic diseases confirmed in upper endoscopy: duodenal ulcer (n = 2), duodenitis with erosion (n = 2), and gastritis with erosion (n = 1), 33.3% of children having alarm features had organic pathology, compared with 2.8% of those without (P < 0.01). A male predominance (80% vs 25.3%, P < 0.01), higher prevalence of alarm features (60% vs 8%, P < 0.01), and higher prevalence of Helicobacter pylori infection (80% vs 5.3%, P < 0.01) were found in children with organic diseases, compared with FD. Multivariate analysis identified H pylori infection (odds ratio 23.2; 95% confidence interval 1.5–333) and nocturnal pain (odds ratio 26.3; 95% confidence interval 1.2–500) to be independent predictors for positive endoscopic findings. Conclusions: Rome III recommendations of screening dyspeptic children for alarm features and investigation for H pylori are effective to identify children who have a higher likelihood of organic diseases and require upper endoscopy before making a diagnosis of FD.

Single-incision Laparoscopic Nephrectomy and Heminephroureterectomy in Young Children Using Conventional Instruments: First Report of Initial Experience

OBJECTIVES To report the surgical technique and the early outcomes of nephrectomy and heminephroureterectomy by single-incision laparoscopic surgery (SILS) in children using conventional laparoscopic instruments only. METHODS Three consecutive children (aged 3, 4 and 7 years) who underwent nephrectomy for multicystic dysplastic kidney (n = 2) and upper moiety heminephroureterectomy for duplex kidney (n = 1) by SILS were retrospectively reviewed. A standardized infraumbilical incision was used for the insertion of 3 reusable ports of 3 and 5 mm. The SILS procedure was performed by the technique of crossing 2 straight instruments. RESULTS All 3 procedures were successfully performed by SILS without any intraoperative complications or need for conversion. The 2 nephrectomies were each completed in 120 minutes, whereas the heminephroureterectomy took 400 minutes. Only 1 dose of narcotic analgesic was required by 1 patient, and 2-6 doses of oral acetaminophen were taken for postoperative pain control. All 3 children recovered smoothly from surgery without complications. CONCLUSIONS Nephrectomy and heminephroureterectomy by SILS using conventional instruments are technically feasible in young children. Further studies are required to investigate whether the SILS approach can become a sound alternative to standard laparoscopy.

Technical report on the initial cases of single-incision laparoscopic combined cholecystectomy and splenectomy in children, using conventional instruments.

Aim. The authors report a technique to perform single-incision laparoscopic combined cholecystectomy and splenectomy in 3 children using conventional instruments. Methods . Three ports, including 5-mm and 3-mm ports, were placed through an infraumbilical incision for the procedure. Splenectomy was completed in most parts by crossing the 2 straight instruments. Results. The 3 patients, aged 11 to 13 years, with body weight 29 kg to 32 kg, underwent the procedure. In the first patient, 2 additional extraumbilical 5-mm ports were required to complete the splenectomy. After modification of the technique, combined cholecystectomy and splenectomy by SILS were successfully performed in the other 2 patients without complications, and postoperative courses were uneventful. Conclusions. Combined cholecystectomy and splenectomy in children by SILS is technically feasible using conventional instruments. Further studies are required to investigate its safety, benefits over conventional laparoscopic surgery, and refinements in the technique.

A Surgeon-Friendly Technique to Perform Single-Incision Laparoscopic Appendectomy Intracorporeally in Children with Conventional Laparoscopic Instruments

BACKGROUND Single-incision laparoscopic appendectomy (SILA) has been successfully performed in children. The intracorporeal approach, using reticulating instruments and 5- to 10-mm ports, has been described in recent reports. In this article, we describe our technique of performing SILA in children, using conventional 3- and 5-mm ports and instruments only. METHODS We conducted a retrospective review of all consecutive children who underwent SILA over a 3-month period by a standardized technique of using one 3-mm and two 5-mm ports. The procedure was completed intracorporeally by conventional instruments, and the specimen was retrieved without wound contamination by a simple method. RESULTS Eleven consecutive children (8-14 years), with a mean body weight of 38.5 kg, underwent successful SILA by our technique during the review period. Mean operating time was 83 minutes. There was no conversion to conventional laparoscopic or open appendectomy. Mean postoperative analgesic requirement was 2.4 doses of oral acetaminophen, and no narcotic analgesic was required. All the patients recovered smoothly without complications. CONCLUSIONS SILA can be safely performed in children when using standard laparoscopic instruments without additional costs in equipment. Using 3- and 5-mm ports seems more appealing to children, with their smaller umbilicus, than adults.

Laparoendoscopic single-site nephrectomy and heminephroureterectomy in children using standard laparoscopic setup versus conventional laparoscopy.

OBJECTIVE To investigate the safety and effectiveness of laparoendoscopic single-site surgery (LESS) using standard laparoscopic setup in pediatric nephrectomy/heminephroureterectomy (HN) by comparing with conventional laparoscopy (CL). METHODS Twelve consecutive children who underwent LESS (nephrectomy = 8, HN = 4) from 2009 to 2012 were compared with a matched cohort of 18 children who underwent CL (nephrectomy = 12, HN = 6) at the same institution. Data were reviewed retrospectively. RESULTS There was no difference between the 2 groups in the age of patients, body weight, gender distribution, laterality of pathology, postoperative analgesic requirement, and hospital stay. Eleven of the 12 children in the LESS group underwent the procedure successfully without additional trocar placement. The only open conversion happened in the case of LESS of the lower moiety HN. LESS nephrectomy took longer operative time than CL (mean 156 +/- 45 vs 99 +/- 35 minutes, median 155 vs 90 minutes, P <.01). Wound infection occurred in 1 patient after CL nephrectomy. No postoperative complication or access site hernia was noted in the children in the LESS group at follow-up. CONCLUSION LESS nephrectomy and HN in the pediatric population is safe and effective with a minimally invasive nature comparable to CL. Learning curve factors may contribute to the reported longer operative time in LESS. Further studies are required to investigate the implication of patient selection and the cosmetic benefits of LESS, which may potentially require longer operative time.

Unexpected metachronous hernia development in children following laparoscopic unilateral hernia repair with negative evaluation for contralateral patent processus vaginalis.

BACKGROUND Metachronous hernia has been reported to develop unexpectedly in children after negative evaluation for contralateral patent processus vaginalis (CPPV) by transinguinal laparoscopy. Scarce data exist regarding such phenomena following laparoscopic unilateral hernia repair and negative findings for CPPV in transumbilical laparoscopy. PATIENTS AND METHODS A retrospective study was performed to investigate metachronous hernia development in a cohort of consecutive children who had undergone laparoscopic unilateral hernia repair with negative findings of CPPV by transumbilical laparoscopy 5 or more years ago. RESULTS Study subjects included 293 children 1 month to 15 years old at the time of laparoscopic unilateral hernia repair (left, n=116; right, n=177). There were 246 boys and 47 girls. Nine children (3.1%), all boys, developed metachronous hernia at a median of 24 months (range, 6-42 months) from the time of negative laparoscopic evaluation for CPPV. There was no statistical difference between the genders and laterality of the initial hernia in the development of metachronous hernia. CONCLUSIONS False-negative CPPV evaluation by transumbilical laparoscopy during laparoscopic unilateral hernia repair can occur and result in unexpected metachronous hernia development. Further prospective studies are warranted to develop effective maneuvers in addition to inspection alone to reduce false-negative laparoscopic assessment.

Early Reoperations after Primary Repair of Jejunoileal Atresia in Newborns

Aim: To review nine-year experience in managing jejuno-ileal atresia (JIA) by primary resection and anastomosis and identify factors associated with reoperations. Methods: From April 2006 to May 2015, all consecutive neonates who underwent bowel resection and primary anastomosis for JIA were analyzed retrospectively. Patients with temporary enterostomy were excluded. Patient demographics, types of atresia, surgical techniques, need for reoperations, and long-term outcomes were investigated. Results: A total of forty-three neonates were included, in which nineteen (44.2%) of them were preterm and fourteen (32.6%) were of low birth weight. Thirteen patients (30.2%) had jejunal atresia whereas thirty patients (69.8%) had ileal atresia. Volvulus, intussusception and meconium peritonitis were noted in 12, 8, and13 patients, respectively. Eight patients (18.6%) had short bowel syndrome after operation. Ten patients (23.3%) required reoperations from 18 days to 4 months after the initial surgery due to anastomotic stricture (n=1), adhesive intestinal obstruction (n=1), small bowel perforation (n=2) and functional obstruction (n=6). Prematurity and low birth weight were associated with functional obstruction leading to reoperation (p=0.04 and 0.01 respectively). The overall long-term survival was 97.7%. All surviving patients achieved enteral autonomy and catch-up growth at a median follow-up of 4.7 years. Conclusion: Long-term survival of JIA after primary resection and anastomosis are excellent. However, patients have substantial risk of early reoperations to tackle intraabdominal complications.