Martin L. Metzelder

Laparoscopic Transabdominal Pyeloplasty in Children is Feasible Irrespective of Age

PURPOSE We assessed the feasibility of laparoscopic transabdominal dismembered pyeloplasty in 46 infants and children with regard to patient age. MATERIALS AND METHODS A total of 46 consecutive infants and children (31 male and 15 female) underwent laparoscopic transabdominal dismembered pyeloplasty using a 3 to 4-trocar technique. All patients had confirmed unilateral deterioration of renal function on isotope renography. The 46 patients were divided into 3 age groups--1 to 12 months (group 1, 14 patients), 1 to 7 years (group 2, 15 patients) and 7 to 18 years (group 3, 17 patients). Followup included clinical and ultrasound assessment, and isotope renography at 3 months. RESULTS Laparoscopic pyeloplasty was feasible in 44 of 46 patients (96%). Mean operative time was 175 minutes (range 120 to 270). The operation was converted due to impracticality of stenting the PUJ in 1 patient, and due to bleeding in 1. Mean operative time in 44 successful laparoscopic procedures was not significantly different among the 3 age groups (171 minutes in group 1, 169 minutes in group 2 and 173 minutes in group 3). Two patients required operative intervention for PUJ leakage, and 1 underwent percutaneous nephrostomy with a further uneventful course. Mean followup was 29 months (range 3 to 86). A total of 44 patients (96%) were asymptomatic and had improved PUJ drainage on isotope renography. Two patients underwent redo pyeloplasty due to recurrent hydronephrosis at 1 month and 2 years. CONCLUSIONS Laparoscopic transabdominal dismembered pyeloplasty is effective and safe in infants and children. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without a disadvantage for the patient.

Role of diagnostic and ablative minimally invasive surgery for pediatric malignancies

The use of minimally invasive surgery (MIS) in pediatric cancer is a matter of debate. The diagnostic and ablative roles of MIS were evaluated in a consecutive series of children with malignancies.

Normalization of serum bile acids after partial external biliary diversion indicates an excellent long-term outcome in children with progressive familial intrahepatic cholestasis.

BACKGROUND/PURPOSE The surgical treatment for patients with progressive familial intrahepatic cholestasis (PFIC) is either liver transplantation (LTX) or partial external biliary diversion (PEBD). Both procedures achieve a good short-term outcome. However, the treatment strategy for these children remains controversial because the long-term outcome after PEBD is unknown. The aim of our study was to assess the long-term outcome and complications after PEBD in our institution. METHODS We retrospectively analyzed the characteristics of all patients with PFIC undergoing PEBD in our department from 1994 to 2008. The course of serum bile acids, pruritus, and liver enzymes was assessed in a regular follow-up. RESULTS Twenty-four patients underwent PEBD. Thirteen patients (54%) improved significantly, with a normalization of serum bile acids (P < .001 vs postoperatively) and lessened pruritus (P < .05 vs preoperatively) at 12 months after PEBD. None of these patients showed progression of cholestasis during a median follow-up of 9.8 years (range, 1.6-14.3 years). Partial external biliary diversion failed to normalize bile acids in 11 patients, of whom 9 required secondary LTX at a 1-year follow-up, with a median interval of 1.9 years (range, 0.5-3.8 years). All 7 patients (100%) with liver cirrhosis at the time of PEBD and 2 of 17 patients without cirrhosis (12%) required secondary LTX (P < .001). CONCLUSIONS Clinical improvement with normalization of serum bile acids within 1 year was associated with an excellent long-term outcome in patients with PEBD. The presence of liver cirrhosis at the time of PEBD indicated an unfavorable outcome. Thus, we recommend primary LTX only in PFIC patients with liver cirrhosis.

Current Status of Laparoscopic Appendectomy in Children: A Nation Wide Survey in Germany

INTRODUCTION Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany. MATERIALS AND METHODS An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects. RESULTS The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training. CONCLUSION LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA.

Impact of prior surgery on the feasibility of laparoscopic surgery for children: a prospective study

BackgroundThis study aimed to determine the impact of prior surgery on the feasibility of laparoscopic surgery for children.MethodsA prospective study analyzed 471 consecutive children who underwent laparoscopic surgery over a 4-year period. Laparoscopic procedures were classified “easy,” “difficult,” or “demanding.” The end points of the study were conversion rate, intraoperative events, and duration of operation.ResultsA total of 89 patients (19%) had undergone previous abdominal surgery. The conversion rate was 18% for the patients with prior surgery versus 9% for those without a prior operation (16/89 vs 35/382; p < 0.05). This difference reflects a significantly higher conversion rate for “easy” procedures among patients with than among those without prior surgery, but not for “difficult” and “demanding” procedures. The type of prior surgery had no significant impact on the mean duration of the operation. Of 71 procedures, 12 (17%) after prior conventional surgery were converted, as compared with 4 (22%) of 18 after prior laparoscopy (p > 0.05). Intraoperative events, mainly attributable to adhesions and lack of overview, occurred in 8% of patients with prior procedures, as compared with 2% without former surgery (7/89 vs 9/382; p < 0.05). Relevant complications were not significantly more frequent after prior surgery. The incidence of conversions decreased with increased time between current and previous surgery. It was 64% for surgeries less than 1 year later, 25% for surgeries 1 to 5 years later, and 5% for surgeries more than 5 years later (7/11 vs 6/24 vs 3/54; p < 0.001).ConclusionsPrior surgery has a limited impact on the feasibility of laparoscopic surgery for children. The conversion rate and the incidence of intraoperative events, mainly because of adhesions and lack of overviewing, is increased, but not the incidence of relevant complications. The feasibility improves considerably with increased time between surgery and prior surgery. The authors consider laparoscopy to be the first-choice technique after prior surgery.

CO2 pneumoperitoneum increases survival in mice with polymicrobial peritonitis.

PURPOSE Laparoscopic techniques are commonly used in patients with bacterial peritonitis. CO2 is known to suppress local and systemic inflammatory responses. Nonetheless, an active immune system is needed to contain bacterial contamination of the abdominal cavity. Therefore, we investigated the early and late effects of CO2 pneumoperitoneum on the ability of mice to overcome polymicrobial peritonitis. MATERIAL AND METHODS Male C57/B6 mice were subjected to pneumoperitoneum with CO2 or helium, or underwent a midline laparotomy. In a first set, changes of arterial blood gases were monitored. In further experiments, polymicrobial peritonitis was induced after 1 h of pneumoperitoneum/laparotomy by cecal ligation and puncture. In a second set of experiments polymicrobial peritonitis was induced 4 h prior to exposure to pneumoperitoneum/laparotomy. After the interventions, survival rates (early survival: 6 to 48 h; late survival > 48 h) were monitored for 7 days. RESULTS There was no significant effect of pneumoperitoneum or laparotomy on arterial blood gas parameters. CO2 pneumoperitoneum significantly reduced the early (6 to 48 h) mortality of subsequent peritonitis after CO2 pneumoperitoneum compared to laparotomy (2/20 vs. 9/25; p < 0.05). The protective effect did not reach significance after 7 days (late mortality). The application of a helium peritoneum did not show any beneficial effect. Application of a CO2 pneumoperitoneum during polymicrobial peritonitis significantly reduced overall mortality (p < 0.05) compared to laparotomy. CONCLUSIONS The modulation of immune responses by CO2, but not helium pneumoperitoneum, has a significant positive impact on survival during abdominal sepsis in a mouse model. Thus, application of a CO2 pneumoperitoneum may be beneficial in conditions with bacterial contamination of the abdominal cavity.

Excision of the Dilated Pelvis is not Necessary in Laparoscopic Dismembered Pyeloplasty

PURPOSE The surgical treatment of choice for significant hydronephrosis is dismembered pyeloplasty. While in open surgery, extensive resection of the dilated pelvis is common practice, laparoscopically usually only a sparing resection is performed. We compared the treatment results of both techniques to investigate whether extensive resection is necessary or not in dismembered pyeloplasty procedures. METHODS To obtain comparable renal units, matched pairs according to age and relative kidney uptake as shown by (123)J-orthoiodohippurate renography were selected out of a total of 76 patients who underwent dismembered pyeloplasty between 2000 and 2007. Twenty-four patients complied with the criteria for inclusion in the study. Changes in urinary drainage preoperatively and at three months postoperatively were compared between both groups. RESULTS The mean age in the sparing resection group was 3.8 years (range 0.3 to 14 years); in the extensive resection group it was 3.4 years (range 0.5 to 10 years). Mean urinary drainage improved significantly in both groups from 35.1 +/- 10.7 % to 75.2 +/- 13.2 % (sparing resection) vs. 45.1 +/- 23.7 % to 70.2 +/- 22 % (extensive resection). There were no differences between the groups (p > 0.05). CONCLUSIONS We conclude that extensive resection of the renal pelvis is not necessary in dismembered pyeloplasty procedures since there were no differences in the renographic outcome of comparable patients treated by the different surgical methods.

Thoracoscopic Biopsy in Children With Diffuse Parenchymal Lung Disease

Lung biopsy is necessary for establishing the diagnosis in patients with otherwise unclassified diffuse or localized parenchymal lung disease. This study aimed to assess the safety and accuracy of video‐assisted thoracoscopic (VATS) lung biopsy in children with diffuse parenchymal lung disease (DPLD). In addition we aimed to evaluate the value of this technique with respect to the spectrum of diseases encountered, correlating histological diagnosis with treatment decisions and subsequent clinical outcome. Data from all patients (n = 21) who underwent surgical lung biopsy for suspected DPLD between March 2001 and August 2006 were collected prospectively. Median age was 3 years, 8 months (range 11 days to 15 years, 2 months). All lung biopsies were performed by VATS under general anesthesia. Median operative time was 45 min (range 25–100 min). Conversion to minithoracotomy due to cardiorespiratory difficulties was necessary in two young infants. There were no further intraoperative complications. In 8/21 children, a chest tube was inserted postoperatively for a median of 2 days (range 1–5 days). In one patient, prolonged air‐leakage was managed thoracoscopically on postoperative day 9. There were no other postoperative complications. The specimens were of adequate volume and quality and a histopathological diagnosis was obtained for all patients. There was a broad spectrum of different diagnoses which led to specific therapeutic decisions. Subsequent medical treatment was beneficial in the majority of the patients. In conclusion, VATS is a safe and effective procedure for diagnosis of children with suspected DPLD. Diagnostic accuracy is high, morbidity rates are low, and patients may benefit from avoiding thoracotomy. Pediatr Pulmonol. 2008; 43:992–996.

The Role of Laparoscopic Techniques in Children with Suspected Post-Transplantation Lymphoproliferative Disorders

AIM To assess the role of minimally invasive surgery (MIS) to diagnose post-transplantation lymphoproliferative disorder (PTLD) in pediatric patients. METHODS Thirty-four patients (20 male, 14 female) underwent organ transplantation (14 liver, 14 kidney, 3 heart, 2 lung, 1 heart-lung) from May 1992 to November 2008 (mean age at transplantation, 66 months; range, 5-277), in whom a biopsy was performed for suspected PTLD from May 1993 to September 2009. The time point of onset, type of PTLD, rate of intraabdominal manifestations with need of MIS, and its accuracy were assessed. RESULTS Twenty-four of 34 patients (70%) had biopsies of superficial lymph nodes (9), oropharyngeal biopsy (5), gastrointestinal endoscopy or bronchoscopy (5), ultrasound-guided biopsies (3), biopsy of the bone marrow (1), or of the orbita (1). Data of the technique used were unavailable in 3 (9%). Due to lack of superficially located lesions, 6 of 34 patients (18%) had laparoscopic biopsy, of which 4 had abdominal organ graft. Laparoscopic biopsy was successful in 5 of 6 cases (83%). Abscess formation at area of transplanted kidney led to conversion in 1. Tumor extension to the abdominal wall led to a primary biopsy via a mini-laparotomy in another case. One patient with abdominal Burkitts lymphoma developed a trocar metastasis, successfully treated by systemic chemotherapy. No other complications were observed after MIS. Accuracy of MIS biopsies was 100%. The onset of PTLD was significantly later diagnosed in cases of explicit intraabdominal PTLD (81 ± 6.3 versus 28 ± 5.3 months; P < .001). Morbidity and mortality were not influenced by biopsy technique or time point of PTLD onset. CONCLUSIONS In 20% of pediatric PTLD cases an intraabdominal biopsy is required due to explicit intraabdominal manifestation. As laparoscopic surgery was even feasible in patients after prior abdominal organ transplantation, we suggest laparoscopic biopsy as a safe tool for diagnosing PTLD.

First Case Studies of Successful ABO-Incompatible Living-Related Liver Transplantation in Infants in Germany

AIM A series study mainly from Asia suggests that ABO-incompatible (ABOi) living-related liver transplantation (LRLT) for pediatric recipients is associated with excellent short- and long-term graft and patient survival. Until now, ABOi LRLT has been rarely performed in Europe. The aim of this study was to analyze the safety and early results of an ABOi LRLT in a German high-volume pediatric liver transplant center. METHODS Six consecutive pediatric patients (four males and two females) were included in this prospective study from January, 2010 to January, 2013 with a median age of 13 months (range, 6-30 months) receiving ABOi LRLT and were matched with six patients receiving ABO-compatible LRLT in the same period. In the ABOi group, titers of IgG and IgM isoagglutinins against the donors blood group were determined at day 14 before the transplantation and from day 1 to 14 after the transplantation, and then twice a week for another 8 weeks. The titer results were determined as the reciprocal number of the highest serum dilution that caused macroscopical reaction. RESULTS The patients receiving ABOi and those receiving ABO-compatible LRLT were comparable regarding the recipients preoperative pediatric end-stage liver disease (PELD), age, gender, and technical aspects of transplantation. The median follow-up was 2.6 years (range, 1-4.5 years). At the time of operation, the mean body weight was 7.7 kg (range, 5.7-16 kg) in ABO-compatible LRLT recipients and 8.8 kg (range, 5.5-18 kg) in ABOi LRLT recipients. In each group, the median PELD score was 28 (range, 28-35), respectively. All recipients received tacrolimus plus mycophenolate mofetil-based standard immunosuppression and four ABOi transplanted patients received intravenous immunoglobulins at days 1, 3, and 5 after liver transplantation. Patient and graft survival in this group was 83%. One female patient died within 24 hours due to fulminant gram-negative sepsis. Another patient developed acute cellular rejection at the 8th postoperative day, which responded to steroid treatment. No further complications occurred. In the ABO-compatible group, patient survival was 100% and graft survival was 83%; one patient in this group received retransplantation after 4 days. During follow-up, two patients of the ABOi group had maximum alloantibody titers of four against the donors blood group; all other patients had titers below four. CONCLUSION ABOi LRLT seems to be safe without an escalation of immunosuppression and should be considered as an additional option to timely facilitate the transplantation.