Nicholas E. Bruns

Telemedicine in pediatric surgery

IMPORTANCE Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. OBJECTIVE To review the current spectrum, potential strategies, and implementation process of telemedicine in pediatric surgery. DESIGN Review and opinion design. SETTING n/a. PARTICIPANTS n/a. MAIN OUTCOMES AND MEASURES: n/a. RESULTS n/a. CONCLUSIONS AND RELEVANCE Telemedicine is an emerging approach with the potential to facilitate efficient, cost-effective delivery of pediatric surgical services. BRIEF ABSTRACT Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program. TYPE OF STUDY Review. LEVEL OF EVIDENCE Level V.

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia

BACKGROUND Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept. METHODS Five pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3-4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10-14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed. RESULTS The first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg. CONCLUSION Magnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

Pediatric Endoscopic Instrumentation

The indications for the use of endoscopic equipment for pediatric surgical conditions primarily involve those that relate to gastrointestinal endoscopy and airway endoscopy, including tracheoscopy and bronchoscopy. The instrumentation for pediatric endoscopy routinely utilized by pediatric surgeons includes a broad spectrum of both flexible and rigid endoscopic tools. The main interventions for pediatric upper intestinal endoscopy, colonoscopy, and airway endoscopy along with commentary of the instrumentation available for these procedures are discussed in this chapter.

Minimally Invasive Approaches to Achalasia

The incidence of achalasia in children is lower than that observed in adults; however, the contemporary management strategies have been similar. Although dilatation and botulinum toxin injection of the lower esophageal sphincter (LES) have been utilized in children, surgical myotomy has resulted in the most reliable definitive therapy for achalasia.

Laparoscopic Pediatric Inguinal Hernia Repair

Inguinal hernia repair is the most commonly performed procedure in infants and children. Over the last 20 years, laparoscopy has advanced and multiple techniques for inguinal hernia repair have been established. In contrary to laparoscopic inguinal hernia techniques for adults, laparoscopic pediatric inguinal hernia repair focuses on closure of the patent processus vaginalis without the use of mesh. This chapter outlines an established technique, while giving mention to other significant minimally invasive procedures.

Laparoscopic Management of Intussusception

Ileocecal intussusception is a frequently encountered problem in pediatric surgical practice. Traditionally, the first-line treatment is pneumatic or hydrostatic reduction, but when unsuccessful, operative reduction or resection is indicated. Over the last 20 years, laparoscopic technique has evolved such that it is commonplace in the surgical management of intussusception. With proper preoperative planning and sound surgical technique, the majority of these cases can be reduced laparoscopically, improving postoperative recovery and cosmesis without the need for laparotomy or bowel resection.

Minimally Invasive Approaches to Esophageal Disorders: Strictures, Webs, and Duplications

Disorders of the esophagus in infants and children are comprised of acquired and congenital conditions. The most common acquired problems of the esophagus are strictures secondary to postoperative esophageal anastomotic complications, and injuries induced following the ingestion of toxic substances (chemicals or lye). Esophageal webs or distal congenital stenosis on the esophagus are very rare, and children present with feeding difficulties. Duplications of the esophagus are often asymptomatic and found incidentally when radiographic imaging of the chest or barium esophagram is performed for unrelated indications. The diagnosis, workup, and minimally invasive surgical management approaches for these conditions in children are described.

Endoscopic Web Localization for Laparoscopic Duodenal Web Excision.

When performing an open duodenal web excision, it is helpful to identify the web using a nasogastric tube because it is often difficult to determine where the web origin is located when looking at the serosal side of the bowel. However, it may be challenging to navigate the nasogastric tube to the web during laparoscopy. We present a novel technique that utilizes intraoperative endoscopy to precisely identify the location of the duodenal web, facilitating laparoscopic excision. Intraoperative endoscopy was implemented in the case of a 3-month-old boy undergoing laparoscopic excision of a duodenal web. With endoscopic visualization and transillumination, the duodenal web was precisely identified and excised laparoscopically. A supplemental video of the case presentation and technique is provided in the online version of this manuscript (Supplemental Digital Content 1, http://links.lww.com/SLE/A134). The procedure was completed successfully and the patient did well postoperatively. Flexible endoscopy is a useful adjunct for duodenal web localization during laparoscopy, improving on the previous method of estimating the location based on a change in duodenal caliber.

Massive retroperitoneal cystic mass in an adolescent.

Anadolescentgirlpresentedtoherpediatricianreportingabdominaldistention.Shefirstbecameawareofherincreasedabdominalgirthwhenfriendsatschoolaskedwhethershewaspregnant.Shehadnoticedherclothingbecomingtighteroverrecentweeks.Shehadnotexperiencedabdominalpainorothersymptoms,andtherewasnohistoryoftrauma.Physicalexaminationre-vealed a firm, distended abdomen without bowelsounds. Pregnancy test results were negative. Resultsoflaboratorystudies,includingacompletebloodcellcount,basicmetabolicpanel,andliverfunctiontests,werewithinnormallimits.Anabdominalradiographshowedapaucityofbowelgasmarkings(Figure1A).Asubsequentcomputedtomographicscanoftheabdomenandpelvisrevealeda30-cmretroperitonealcysticstructurecausingsignificantmasseffectontheabdominalviscera,displacingtherightkidneysuperiorlyunderthelivercausingmod-eratehydronephrosis(Figure1B).