Pkh Tam

Prospective randomized single-center, single-blind Comparison of laparoscopic vs open repair of pediatric inguinal hernia

BackgroundThe repair of indirect inguinal hernia (IH) is one of the most common pediatric surgical procedures, and open surgery (OS) is the standard treatment. The aim of this study was to determine whether the recently developed laparoscopic repair (LR) of IH is superior to OS.MethodsBetween February 2003 and February 2004, we randomly assigned 97 consecutive IH patients at our institution into OS and LR groups. Fourteen pateints were excluded from the study for various reasons, leaving study population of 83 patients. After operation, multiple dressings were placed to blind observers to the operation type. Two pain scales, the children and Infants Postoperative Pain were used to assess postoperative pain. Acetaminophen (15 mg/kg/dose every 6 h) was given at a fixed pain score. Analgesic doses were compared. Parents also provided assessments of their children’s recovery and wound appearance.ResultsThe amount of acetaminophen taken by the OS group (n = 42) was 1.05 ± 1.248 doses per patient, whereas the amount taken by the LR group (n = 41) was 0.54 ± 0.84 dose per patient (p = 0.032; 95% confidence interval 0.45–0.976). Laparoscopy detected 11 more bilateral hernias (p = 0.006). Although the operative times did not differ significantly for bilateral hernias (39.08 ± 13.37 min vs 34.0 ± 11.31 min, p = 0.623), it did differ for unilateral hernias (18.38 ± 5.71 vs 23.25 ± 6.26 min, p = 0.001). Five contralateral hernias were detected in the OS group on follow-up, but none were found in the LR group (p = 0.026). The scores given by parents for recovery and wound appearance were higher in the LR group (p = 0.05).ConclusionsAs compared with IH patients who undergo open surgery, those who have a laparoscopic repair suffer less pain, and their recovery and wound cosmesis are more satisfactory. With LR, contralateral hernias can be detected and repaired in a single operative procedure. This procedure takes slightly longer for unilateral than for bilateral hernias.

Upregulation of macrophage migration inhibitory factor contributes to induced N-Myc expression by the activation of ERK signaling pathway and increased expression of interleukin-8 and VEGF in neuroblastoma.

Macrophage migration inhibitory factor (MIF) has been linked to fundamental processes such as control of cell proliferation, cell survival, angiogenesis, and tumor progression. The expression of MIF has been reported in several tumors. However, the precise role of MIF in tumor cells remains unclear. In the present study, we investigated the expression pattern and the function of MIF in neuroblastoma. Our results showed that intracellular MIF was upregulated in neuroblastoma tumor tissues and cell lines. MIF protein expression significantly correlated with the grade of tumor differentiation. In addition, we found that MIF induced a significant dose-dependent increase of vascular endothelial growth factor and interleukin-8 secretion. We also observed that an increased MIF expression level correlated with N-Myc protein (the N-myc oncogene product) expression in neuroblastoma tissues. MIF increased the expression of N-myc mRNA and N-Myc protein and induced N-Myc translocation from the cytoplasm to nucleus in neuroblastoma cell lines. MIF-induced N-Myc expression was found to be dependent on ERK signaling pathways. The inhibition of ERK activation reduced MIF-mediated N-Myc expression. These results suggest that MIF may contribute to the progression of neuroblastoma by (a) inducing N-Myc expression and (b) upregulating the expression of angiogenic factors.

Earlier appearance and higher incidence of the rectoanal relaxation reflex in patients with imperforate anus repaired with laparoscopically assisted anorectoplasty

Background: This study aimed to evaluate clinically and manometrically the anorectal function of patients with imperforate anus after repair with laparoscopically assisted anorectoplasty (LAR), as compared with the function of patients after undergoing the conventional method, posterior sagittal anorectoplasty (PSARP). Methods: The defecation status and anorectal manometry of patients with high or intermediate type imperforate anus repaired with LAR (n = 9) and age-matched patients repaired with PSARP (n = 13) were assessed and compared during the first year of postoperative follow-up evaluation. The defecation status was classified by the frequency of bowel openings (<1, 1–4, and >5 times per day). Manometric assessment was performed by an open-tip hydraulic capillary infusion system. The presence of the rectoanal relaxation reflex was determined, and the resting sphincteric pressure and resting rectal pressure were measured. Results: Seven of nine LAR patients had an “acceptable” frequency of one to four bowel openings per day, in contrast to 7 of 13 PSARP patients. The difference in the presentation of daily stooling is not significant (p > 0.05). A positive RAR was detected in 88.9% (8/9) of the LAR patients, and in only 30.8% (4/13) of the PSARP patients (p < 0.01). The presence of a rectoanal relaxation reflex also significantly correlated with an acceptable frequency of bowel opening (1–4 times per day) in both LAR and PSARP patients (p < 0.05). Moreover, a rectoanal relaxation reflex was detected significantly earlier in LAR than in PSARP patients (4.9 ± 1.2 vs 10.1 ± 2.5 months; postoperatively p < 0.0001). Both the LAR and PSARP patients had a similar resting sphincteric pressure (21.5 ± 4.7 vs 25.4 ± 6.2 cm H2O; p > 0.05). By contrast, the resting rectal pressure was significantly lower in LAR than in PSARP patients (7.7 ± 1.5 vs 11.5 ± 1.3 cmH2O; p < 0.05). Conclusions: In the early postoperative stage, patients repaired with LAR had more favorable findings in anorectal manometry than patients repaired with PSARP. Long-term follow-up studies to confirm a superior defecation continence achieved with LAR are warranted.

Post-operative magnetic resonance evaluation of children after laparoscopic anorectoplasty for imperforate anus

Background and aimsLaparoscopic anorectoplasty (LAR) is a relatively new procedure in the treatment of imperforate anus. Using magnetic resonance imaging (MRI), we evaluated the anatomical features of the anorectal region of children treated with LAR and compared this with conventional posterior sagittal anorectoplasty (PSARP). The findings were correlated with functional outcome.Patient/methodsA retrospective review of ten children with the high/intermediate types of imperforate anus underwent LAR between May 2000 and December 2002. MRI of the pelvis was performed post-operatively and a semi-quantitative score was used to assess the degree of sphincter symmetry, peri-rectal fibrosis, and the position of the pull-through rectum. The defecation status of these patients was also recorded. Eight historical patients who had undergone PSARP served as a control group.Results/findingsWhen compared with PSARP patients, a significantly lower proportion of LAR patients had sphincter asymmetry (40 vs. 100%, p<0.05) and peri-rectal fibrosis (40 vs. 87.5%, p<0.05). The positioning of the rectum was, however, central for both groups (90 vs. 87.5%). No statistical correlation was found between defecation status and the degree of sphincter asymmetry or peri-rectal fibrosis.Interpretation/conclusionLAR allows more optimal anatomical reconstruction for patients with the high/intermediate types of imperforate anus. However, additional factors that are not correctable by surgery, such as intrinsic innervation deficiency, also influence the clinical outcome.

Deficient motor innervation of the sphincter mechanism in fetal rats with anorectal malformation: a quantitative study by fluorogold retrograde tracing

BACKGROUND/PURPOSEnDeficiency of motoneuron innervation to the sphincter mechanism has been described in patients with anorectal malformation. Whether this event is primary or secondary remains unclear.nnnMETHODSnThe authors quantified the motoneuron innervation of the sphincter mechanism by Fluorogold (FG) retrograde tracing experiment in fetal rats with anorectal malformation. Anorectal malformation was induced in rat fetuses by ethylenethiourea (ETU). Serial longitudinal sections encompassing the whole width of lumbosacral spinal cord were examined. The number of FG-labelled motoneurons were scored and compared between male fetuses with or without malformation in the ETU-fed group and normal controls.nnnRESULTSnThe number of FG-labelled motoneurons in the fetuses without defect, with imperforate anus (IA), with neural tube anomalies (NTA), with combined IA and NTA, and normal controls were determined to be (mean +/- SEM) 109.13 +/- 37.88, 55.05 +/- 25.85, 48.20 +/- 30.34, 54.43 +/- 28.55, and 135.22 +/- 28.78, respectively. FG-labelled motoneurons in the fetuses with IA, NTA, and combined IA and NTA are significantly fewer than that in fetuses without defects (P <.05) and in normal controls (P <.005).nnnCONCLUSIONSnThese findings suggest that defective motoneuron innervation to the sphincter mechanism is a primary anomaly that coexists with the alimentary tract anomaly in anorectal malformation during fetal development. The intrinsic neural deficiency is an important factor likely to contribute to poor postoperative anorectal function despite surgical correction of anorectal malformation.

Diagnosis and evaluation of esophageal atresia by direct sagittal CT

Direct sagittal CT is possible in newborns because of their small body-size. With this noninvasive investigation, we were able to establish a correct diagnosis in two neonates with esophageal atresia. Moreover, the demonstration of the air-filled proximal pouch and distal tracheoesophageal fistula along their whole lengths allowed exclusion of the possibility of a proximal pouch fistula and gave knowledge of the exact distance of the two segments of the esophagus needed to be bridged to allow anastomosis, thus providing additional valuable information for the surgeon preoperatively.

Long-term follow-up of childhood duodenal ulcers

PURPOSEnThis study reports the long-term results in children who have duodenal ulcers diagnosed by endoscopy who were treated with H2-receptor antagonist.nnnMETHODSnThe medical records of 32 children admitted into The Queen Mary Hospital with endoscopically proven duodenal ulcers between 1975 and 1988 were reviewed to evaluate the long-term outcome of childhood duodenal ulcers after initial treatment with H2-receptor antagonist (H2RA). Follow-up details were updated and patients who had been lost to follow-up were recalled. The age of the 22 boys and 10 girls at the time of diagnosis of the ulcers ranged from 3 to 16 years (mean, 11.8 yrs). The duration of follow-up ranged from 8.5 to 21 years (mean, 11.6 yrs).nnnRESULTSnTheir primary presentations included epigastric pain (n = 9, 28.0%); nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB, n = 6, 18.7%); unprovoked GIB (n = 12, 37.5%); perforation (n = 4, 12.5%); and pyloric obstruction (n = 1, 3.0%). All 13 patients who had NSAID-induced ulcers (pain and bleeding) responded to H2RA therapy and required no further treatment. All 14 patients who had unprovoked ulcers who presented with pain or bleeding did not respond to H2RA treatment. Ulcer healing was achieved only after eradication of Helicobacter pylori with antibiotics (n = 8) or definitive surgery involving either truncal vagotomy and pyloroplasty (VP, n = 4) or proximal gastric vagotomy (PGV, n = 2). The patient who had gastric outlet obstruction had vagotomy and antrectomy. All four patients who had perforation were initially treated with patch repair, but two had persistent ulceration despite H2RA treatment and required PGV. Complications developed in none of the four patients who had PGV, whereas two of the four patients with VP had problems (diarrhea, n = 1; bezoar obstruction, n = 1).nnnCONCLUSIONSnUnprovoked childhood duodenal ulcer is associated with significant long-term morbidity and requires continued follow-up. The majority of the ulcers are resistant to H2RA treatment alone and ultimately require either eradication of H. pylori or surgery. In the absence of obstruction, PGV may be enough to resolve the ulcer diathesis.

Thoracoscopic resection of congenital cystic lung lesions is associated with better post-operative outcomes

IntroductionThe incidence of congenital cystic lung lesions has been increasing in recent years due to better antenatal detection. With the introduction and maturation of thoracoscopy, the operative management for these lesions has seen advancement in the last decade. In this study, we aimed to compare the post-operative outcomes of patients who had thoracoscopic resection with those who underwent open resection.MethodsA retrospective review of all patients who underwent surgery for congenital cystic lung lesions between January 1996 and June 2012 in a tertiary referral center was conducted. Patients’ demographics, operative procedures and post-operative outcomes were analyzed.ResultsSixty-seven patients were identified over the past 15xa0years. Thirty-nine patients had thoracoscopic resections and 28 had open resections. Thirteen patients in the thoracoscopic group required conversion. Both groups had similar demographics in terms of age, body weight and laterality of lesions. The mean operative time and blood loss in the two groups were comparable. Patients in the thoracoscopic group had significantly shorter duration of chest tube drainage (4.3 vs. 6.9xa0days, pxa0=xa00.004), shorter intensive care unit stay (2.5 vs. 5.9xa0days, pxa0=xa00.003) and shorter hospital stay (6.9 vs. 12.0xa0days, pxa0<xa00.001). Post-operative complication rate was similar between the two groups. Patients with body weight less than 5xa0kg showed a significantly higher conversion to open surgery as compared to those with body weight more than 5xa0kg (62.5 vs. 25.8xa0%, pxa0=xa00.049).ConclusionSuccessful thoracoscopic resection for congenital cystic lung lesions results in better post-operative outcomes. However, this technique remains technically challenging in patients with body weight less than 5xa0kg.

Successful right trisegmentectomy for ruptured hepatoblastoma with preoperative transcatheter arterial embolization

This is the first report of the successful use of percutaneous transcatheter arterial embolization (TAE) in controlling hemorrhage from ruptured hepatoblastoma, allowing early major hepatic resection to be performed safely in a young infant. A 6-month-old girl presented with a huge abdominal mass and was found to have a hepatoblastoma that measured 15 x 10 x 12 cm and arose from the right lobe of her liver on computed tomography (CT) scan examination. The tumor spontaneously ruptured, and she went into shock. TAE with gelfoam cube particles successfully arrested the tumor bleeding and allowed stabilization of her blood pressure with blood transfusion. Right trisegmentectomy was performed 12 hours later. The postoperative course was uneventful. With three courses of cisplatin, vincristine, and 5-fluorouracil after the hepatectomy, the serum alpha-fetoprotein level returned to normal, and the patient has remained well 4 months postoperation.

Thoracoscopic repair of oesophageal atresia: experience of 33 patients from two tertiary referral centres.

BACKGROUNDnWith advances in minimally invasive surgery, thoracoscopic repair of oesophageal atresia has become popular in many centres worldwide and indeed has been described as the pinnacle of neonatal surgery. Here, we report our experience in two tertiary referral centres.nnnMETHODSnThoracoscopic technique was introduced in 2007. Thus, a retrospective review of all patients diagnosed with oesophageal atresia was carried out. Patients who had thoracoscopic repair were included, and those who had open repair due to co-morbidities were excluded. Patient demographics, operative data, complications, and associated anomalies were noted.nnnRESULTSnA total of thirty-three patients underwent thoracoscopic repair during the time period. Thirty-one were successfully repaired thoracoscopically. Two patients had conversions due to intra-operative instability. The mean body weight of the neonates was 2.58 kg. The mean operative time was 146 min. Three patients suffered from minor anastomotic leaks, which healed on conservative management. Seven patients had anastomotic strictures, which responded successfully to endoscopic dilatation. Two patients died in the post-operative period due to pneumonia. One patient had a recurrent fistula 3 months after the primary repair, and he subsequently underwent a successful second repair.nnnCONCLUSIONSnIn experienced hands, thoracoscopic repair of oesophageal atresia is at least as good as open surgery but with less surgical trauma. Standard of post-operative care contributes significantly to post-operative outcome. Thoracoscopic technique is now our preferred approach.