Rainer Kubiak

Long-term outcome of laparoscopic nissen fundoplication compared with laparoscopic thal fundoplication in children: a prospective, randomized study.

Background:Laparoscopic fundoplication is increasingly performed in pediatric surgery. Many types of fundoplication are performed, each has advantages and disadvantages. To date there has been no prospective randomized study to determine the optimal laparoscopic technique in children. The aim of the study was to compare the long-term outcomes and control of symptoms after laparoscopic Nissen fundoplication with laparoscopic Thal fundoplication in children. Methods:Between July 1998 and April 2007, 175 patients were recruited to this prospective, randomized study. Patients were assessed before the operation and after defined intervals starting at 3 months after surgery. The “absolute” outcome measure for fundoplication failure was recurrence of symptoms that merited a redofundoplication or insertion of a transgastric jejunostomy. “Relative” outcome measures were recurrence of symptoms necessitating reintroduction of antireflux medication (ie, “intention to treat”) and postoperative complications (eg, postoperative dysphagia). The median follow-up time was 30 months (range, 1–109). This study has been registered with clinicaltrials.gov (NCT01027975). Results:Long-term results were available in 167 patients of which 85 underwent a Nissen and 82 a Thal fundoplication. Four patients in the Nissen group (4.7%) and 12 in the Thal group (14.6%) required a redofundoplication. One child in each group developed recurrence of symptoms and had a transgastric jejunostomy performed. The “absolute” failure rate was significant lower in the Nissen group (n = 5; 5.9%) compared with the Thal group (n = 13; 15.9%) (P = 0.038). The vast majority of these patients (17 of 18) had underlying neurological disorders. The “relative” failure rate (ie, “intention to treat”) was similar in both groups. Nearly one-quarter of patients developed postoperative dysphagia similarly distributed between both groups. However, severe dysphagia requiring endoscopy +/− dilatation was significantly higher in the Nissen group (n = 10, 11.8%) compared with the Thal group (n = 2; 2.4%) (P = 0.020). One of 31 deaths (0.6%) in this series occurred after surgery, but was not directly related to the fundoplication technique. Conclusions:In the long-term a laparoscopic Nissen fundoplication had a significantly lower recurrence rate than a Thal fundoplication, particularly in patients with underlying neurological disorders. There was no significant difference between the 2 types of fundoplication in normal children. There was no significant difference between the need for restarting antireflux medication between both groups because of recurrence of moderate symptoms. The incidence of postoperative dysphagia was similar in the 2 groups, however, significantly more patients in the Nissen group required intervention for severe dysphagia. Overall the perioperative death rate was low even in high-risk patients.

Laparoscopy-assisted single-port appendectomy in children: is the postoperative infectious complication rate different?

AIM In childhood, laparoscopy-assisted single-port appendectomy (SPA), including the advantages of open and laparoscopic surgery, is not widely used. However, there is debate whether the retrieval of the infected appendix via the umbilicus results in a higher infection rate compared with other laparoscopic or open techniques. The aim of the study was to determine the postoperative infection rate and possible risk factors for infection after SPA in children. METHODS For this retrospective study, case notes of all children (n = 262) who underwent SPA between August 2005 and December 2008 were reviewed. Those children in whom the preoperative ultrasonography revealed suspected perforation were excluded from SPA and subsequently underwent open surgery. SPA was performed using a 12-mm trocar with one 5-mm working channel, introduced through a sub-umbilical incision. After grasping the appendix with atraumatic forceps, the appendix was exteriorized through the umbilicus and dissected outside the abdominal cavity as in open surgery. Preoperatively, each patient received one dose of Metronidazole and Cefuroxime, and the umbilicus was cleaned in particular. RESULTS Of the 262 children who underwent SPA, 146 were boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1-15.9). Six obese (with a body mass index greater than the 95th percentile) children (2.3%) developed intra-abdominal abscess after perforated appendicitis that was treated with a course of antibiotics. One child required revisional surgery and drainage. The median length of antibiotic treatment was 3 days (range, 0-15). CONCLUSION In our institution, SPA is the method of choice for appendectomy in children with acute appendicitis, in whom preoperative ultrasound does not reveal signs of perforation. The infection rate (2.7%) after SPA is not increased compared with other laparoscopic or open techniques. Overweight (body mass index greater than the 95th percentile) and perforated appendicitis seem to increase the risk of postoperative infectious complications.

Laparoscopic Nissen Fundoplication Versus Thal Fundoplication in Children: Comparison of Short-Term Outcomes

BACKGROUND The aim of this study was to compare short-term outcomes, including intra- and perioperative complications following laparoscopic Nissen versus Thal fundoplication. PATIENTS AND METHODS From July 1998 until April 2007, 175 patients were recruited. Patients were prospectively randomized to either a Nissen wrap or a Thal wrap. Observation period was 6 weeks after surgery. RESULTS 89 Nissen and 86 Thal were performed. The mean age at the time of operation (OP) was 5.2 years. Demographics were similar, although weight at OP was significantly less in the Nissen group. Intraoperative complications during a Nissen included bleeding from a liver laceration in 2 patients (1 required conversion) and small bowel perforation during open port insertion in 1 patient. There were two conversions in the Thal group, due to bleeding from the omentum in 1 patient and equipment failure in the other. In a third patient the colon was perforated during insertion of percutaneous endoscopic gastrostomy (PEG) and repaired laparoscopically. Post-OP dysphagia was similarly distributed among both groups, but was significantly more severe after a Nissen (P = 0.018). There were two early deaths: in the Nissen group, 1 child died from peritonitis after the gastrostomy tube fell out, whereas one death in the Thal group was caused by respiratory failure associated with the patients underlying condition. CONCLUSIONS There was no statistical difference in the short-term outcomes between laparoscopic Nissen and Thal fundoplication, apart from a higher rate of esophagoscopy for severe dysphagia in the Nissen group. The higher number of postoperative complications in the Nissen group was largely due to gastrostomy-related problems.

Comparison of long-term outcomes between open and laparoscopic Thal fundoplication in children.

OBJECTIVES In recent years laparoscopic fundoplication is increasingly performed in pediatric surgery. The aim of this study was to compare the long-term outcomes between open and laparoscopic Thal fundoplication in children. METHODS This retrospective study includes children who underwent a Thal fundoplication between 3/1997 and 7/2009. The minimum follow-up time to enter the study was 2 years; the overall median follow-up was 77 months (range, 29-176 months). RESULTS A total of 101 patients were included, of which 47 underwent an open and 54 a laparoscopic Thal. Intraoperative problems, early postoperative complications, time to establish enteral feeds and length of stay did not differ among both groups. The mean duration of surgery was significantly less in the open group (OPG) (108.0 (± 7.72) versus 144.1 (± 6.36) minutes; p=0.001) and this was mainly attributed to patients with neurological problems. Severe dysphagia requiring endoscopy was observed in 10 patients, but this did not differ significantly between groups (n=2 in the OPG vs. n=8 in the laparoscopic group (LAPG); p=0.10). Overall 12 patients (11.9%) (6 in each group) required a redo-fundoplication after a median of 18.7 months (range, 6-36 months). In the whole study group, 80 patients (79.2%) were classified as having surgical results being excellent, good or satisfactory and this did not differ significantly between groups. CONCLUSIONS In the long-term open and laparoscopic Thal fundoplication have similarly good outcomes. The laparoscopic approach can be considered as an alternative, however there is not a clear superiority compared with the open counterpart.

Percutaneous collagen induction as an additive treatment for scar formation following thermal injuries: Preliminary experience in 47 children

BACKGROUND Thermal injuries are one of the most physically and psychologically devastating causes of pediatric trauma. Post-traumatic sequelae such as hypertrophic scars and contractures often result in long lasting morbidity and disfigurement. Conservative therapy, including pressure garments and silicone, is the gold standard for scar management in the pediatric population. Most recently percutaneous collagen induction (PCI) was introduced as an alternative treatment in adults. The aim of this report was to share our experience with PCI in children and adolescents in scar management following thermal injuries. PATIENTS AND METHODS Between July 2013 and February 2016, a total of 99 PCI treatments were performed on forty-seven children and adolescents for scar formation following thermal injuries in this retrospective study. A medical roller device (Dermaroller®, Dermaroller GmbH, Wolfenbüttel, Germany) with 2.5mm long needles was used. All procedures were carried out under general anesthesia. At the end of the operation vitamin A and vitamin C oil (ENVIRON® AVST Body Oil; Environ Skin Care, Pty. Ltd., Cape Town, South Africa) was applied topically. Photographs were taken before and a minimum of 4 weeks after the first PCI in order to document the effect on scar tissue. These images were graded according to the Vancouver Scar Scale (VSS). RESULTS The median age at the time of the first PCI was 8.3 years (range, 0.8-21.2 years). The median time interval between the injury and PCI was 18 months (range, 4-170 months). There were no intraoperative problems noted. Minor postoperative complications occurred in 2 patients (4.3%). All patients reported subjective improvement and were satisfied with the procedure and the results. Pre- and post-treatment photographs were available in 40 patients, and overall VSS scores improved post-treatment in all patients. Following a single PCI treatment, scar vascularity, pliability and height all improved, however there was no statistically significant effect on pigmentation. CONCLUSIONS PCI is an enrichment of the armamentarium for scar treatment following thermal injuries in children and adolescents. Further prospective studies are recommended regarding the optimal timing for this treatment and long term outcome in the pediatric population.

Use of covered self-expandable stents for benign colorectal disorders in children

PURPOSE There is a lack of experience with covered self-expandable stents for benign colorectal disorders in children. METHODS Five children (4M, 1F) with a median age of 5years (range, 6months-9years) who underwent treatment with covered self-expandable plastic (SEPSs) or self-expandable metal stents (SEMSs) for a benign colorectal condition between April 2005 and November 2013 were recruited to this retrospective study. Etiologies included: anastomotic stricture with (n=1) or without (n=3) simultaneous enterocutaneous fistula, as well as an anastomotic leak associated with enterocutaneous fistula (n=1). All children suffered from either Hirschsprungs disease (n=3) or total colonic aganglionosis (Zuelzer-Wilson syndrome) (n=2). RESULTS Median duration of individual stent placement was 23days (range, 1-87days). In all cases up to five different stents were placed over time. At follow-up two patients were successfully treated without further intervention. In another patient the anastomotic stricture resolved fully, but a coexisting enterocutaneous fistula persisted. Overall, three patients did not improve completely following stenting and required definite surgery. Stent-related problems were noted in all cases. There was one perforation of the colon at stent insertion. Further complications consisted of stent dislocation (n=4), obstruction (n=1), formation of granulation tissue (n=1), ulceration (n=1) and discomfort (n=3). CONCLUSIONS Covered self-expandable stents enrich the armamentarium of interventions for benign colorectal disorders in children including anastomotic strictures and intestinal leaks. A stent can be applied either as an emergency procedure (bridge to surgery) or as an adjuvant treatment further to endoscopy and dilatation. Postinterventional problems are frequent but there is a potential for temporary or definite improvement following stent insertion.

Laparoscopic fundoplication in children with ventriculo-peritoneal shunts.

BACKGROUND Children with ventriculo-peritoneal (V-P) shunts have a significant risk of morbidity and mortality from infections. Many of these patients have other co-morbidities and may require subsequent abdominal surgery, including fundoplication with or without gastrostomy placement. The aim of our study was to assess the outcomes of laparoscopic fundoplication in children with a V-P shunt in situ. SUBJECTS AND METHODS A retrospective review of a prospectively maintained database on children who underwent laparoscopic fundoplication with a V-P shunt in situ at the time of surgery between July 1998 and March 2011 was conducted. Primary outcomes included intra- and postoperative complications as well as shunt-related problems within a 6-month period after surgery. The subset of children with V-P shunts was compared with those who underwent fundoplication without shunts. Variables were compared using the two-tailed Students t test, chi-squared test, or Fishers exact test. Significance was defined as P≤.05. RESULTS Out of a total of 343 children who underwent fundoplication, 11 (6 girls, 5 boys) had a V-P shunt in situ at the time of surgery (3.2%). The median age at laparoscopy was 2.2 years (range, 0.7-13.8 years). Weight at surgery ranged from 5.8 to 39.0 kg (median, 12.0 kg). The operating time (without gastrostomy placement) was 105 minutes (range, 80-140 minutes). In 6 patients (55%) moderate to severe adhesions were documented, but only 1 child required conversion to open surgery because of bleeding from the omentum. In a second patient the colon was perforated during insertion of the percutaneous endoscopic gastrostomy (PEG) and repaired laparoscopically. There was no postoperative shunt dysfunction or infection related to the laparoscopic procedure. There was no significant difference between V-P shunt patients and the main cohort regarding operating time, conversion to open surgery, need for admission to a high-care unit, opiate requirements, time to full feeds, and length of hospital stay. CONCLUSIONS These data suggest that laparoscopic fundoplication is feasible in children with previous V-P shunt placement. Although there were considerable adhesions in approximately half of these patients, the rate for conversion to open surgery was low. Complications associated with simultaneous PEG insertion occur and should be anticipated by placing the gastrostomy under laparoscopic guidance.

Die Behandlung der Condylus-radialis-humeri-Fraktur im Kindesalter@@@Treatment of Lateral Humeral Condyle Fractures in Children

OBJECTIVE Surgical treatment of lateral humeral condyle fractures with reduction and retention in order to prevent lasting malalignment, pseudarthrosis, and joint instability. INDICATIONS Absolute: fractures with a complete dislocation or those in which plaster-free control X-ray on day 4 shows a gap of > 2 mm. Relative: complete fractures of the lateral humeral condyle which demonstrate a dislocation < or = 2 mm on follow-up. CONTRAINDICATIONS Incomplete, so-called hanging fractures of the lateral humeral condyle without notable secondary dislocation on follow-up. SURGICAL TECHNIQUE Open reduction of the lateral humeral condyle via a lateral approach to the elbow joint. In smaller children (< 5 years of age) fixation with Kirschner wires. In older children (> or = 5 years of age) or in cases requiring compression radial screw fixation is recommended. In all cases, suture repair of the periosteum is advisable. POSTOPERATIVE MANAGEMENT Long upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3-4 weeks postoperatively. Implants are removed following consolidation (confirmed by X-ray) after approximately 2-3 months. Routine physiotherapy is normally not required. RESULTS From January 1, 1999 to December 31, 2006, 85 children with a median age of 6.1 years had lateral condyle fracture of the humerus treated. 47 patients underwent surgery. Of these, 31 were treated with a combination of screw and Kirschner wire fixation, 13 with a single screw, and in three cases, the fracture was fixed with Kirschner wires only. After a median of 8.6 weeks (range, 5.0-17.1 weeks), implants were removed. Median follow-up time was 6 months (range, 2-50 months). There were no late complications in this series (e.g., lack of consolidation, pseudarthrosis). In five cases, hyposensitivity of the skin above the proximal aspect of the radial bone was noted postoperatively. This problem was solved in all instances within the following 6 months. A telephone survey with a response rate of 87% (74 patients) was undertaken in September 2007. Three children noted a minimal deficiency in strength of the injured arm in comparison to the contralateral extremity. One of these children additionally stated a minor flexion deficit of the elbow already present at the last follow-up in the outpatient clinic, which showed no progress. None of the patients had to be referred back to the outpatient clinic because of persistent problems and/or unacceptable results.ZusammenfassungOperationszielOperative Reposition und Retention des Condylus radialis humeri zur Vermeidung von bleibenden Fehlstellungen, Pseudarthrosen und Gelenkinstabilitäten.IndikationenAbsolut: Primär vollständig dislozierte Frakturen oder Frakturen, die nach 4 Tagen im gipsverbandfreien Kontrollröntgen eine Sekundärdislokation von > 2 mm aufweisen.Relativ: Komplette Frakturen des Condylus radialis humeri, die im Verlauf eine Sekundärdislokation von ≤ 2 mm aufweisen.KontraindikationenInkomplette, sog. hängende Frakturen des Condylus radialis humeri ohne erkennbare Sekundärdislokation im Verlauf.OperationstechnikOffene Reposition des Condylus radialis humeri über einen lateralen Zugang am Ellenbogengelenk. Bei jüngeren Kindern (< 5 Jahre) Kirschner-Draht-Fixierung. Bei älteren Kindern (≥ 5 Jahre) oder bei unzureichender Kompression Durchführung einer radialen Zugschraubenosteosynthese. Zusätzliche Periostnaht.WeiterbehandlungAnlage einer Oberarmgipslonguette bis zum Abschluss der Wundheilung; im Anschluss Oberarmgipsverband für insgesamt 3–4 Wochen nach der Operation. Materialentfernung bei Konsolidierung (Röntgen) nach ca. 2–3 Monaten. Keine routinemäßige postoperative Physiotherapie.ErgebnisseIm Zeitraum vom 01.01.1999 bis 31.12.2006 wurden insgesamt 85 Kinder mit einem Altersmedian von 6,1 Jahren wegen einer Condylus-radialis-humeri-Fraktur behandelt. 47 Patienten wurden operativ versorgt, davon 31 Kinder mit einer Kombination aus Schraube und Kirschner-Drähten, 13 Kinder mit einer Schraube allein und drei Kinder nur mit Kirschner-Drähten. Die Implantate wurden im Median 8,6 Wochen (5,0–17,1 Wochen) postoperativ entfernt. Insgesamt betrug die mediane Nachbeobachtungszeit 6 Monate (2–50 Monate). Bei keinem Patienten in dieser Serie traten Spätkomplikationen im Sinne einer nicht stattgefundenen Konsolidierung und/oder einer Pseudarthrosenbildung auf. In fünf Fällen mit Hypästhesien im Bereich der Haut über dem proximalen Radius kam es binnen 6 Monaten nach der Operation zu einer vollständigen Normalisierung.Im Rahmen eines Telefoninterviews im September 2007 konnten 87% der Patienten (n = 74) nachverfolgt werden. Drei Kinder gaben eine geringe Minderung der groben Kraft des verletzten Arms im Seitenvergleich an, wobei eines dieser Kinder zusätzlich ein geringes Ellenbogenflexionsdefizit berichtete, welches im Vergleich zur letzten klinischen Untersuchung nicht progredient war. In keinem der telefonisch kontaktierten Fälle war es nötig, den Patienten aufgrund persistierender Beschwerden und/oder eines subjektiv nicht akzeptablen Behandlungsergebnisses akut erneut einzubestellen.AbstractObjectiveSurgical treatment of lateral humeral condyle fractures with reduction and retention in order to prevent lasting malalignment, pseudarthrosis, and joint instability.IndicationsAbsolute: fractures with a complete dislocation or those in which plaster-free control X-ray on day 4 shows a gap of > 2 mm.Relative: complete fractures of the lateral humeral condyle which demonstrate a dislocation ≤ 2 mm on follow-up.ContraindicationsIncomplete, so-called hanging fractures of the lateral humeral condyle without notable secondary dislocation on follow-up.Surgical TechniqueOpen reduction of the lateral humeral condyle via a lateral approach to the elbow joint. In smaller children (< 5 years of age) fixation with Kirschner wires. In older children (≥ 5 years of age) or in cases requiring compression radial screw fixation is recommended. In all cases, suture repair of the periosteum is advisable.Postoperative ManagementLong upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3–4 weeks postoperatively. Implants are removed following consolidation (confirmed by X-ray) after approximately 2–3 months. Routine physiotherapy is normally not required.ResultsFrom January 1, 1999 to December 31, 2006, 85 children with a median age of 6.1 years had lateral condyle fracture of the humerus treated. 47 patients underwent surgery. Of these, 31 were treated with a combination of screw and Kirschner wire fixation, 13 with a single screw, and in three cases, the fracture was fixed with Kirschner wires only. After a median of 8.6 weeks (range, 5.0–17.1 weeks), implants were removed. Median follow-up time was 6 months (range, 2–50 months). There were no late complications in this series (e.g., lack of consolidation, pseudarthrosis). In five cases, hyposensitivity of the skin above the proximal aspect of the radial bone was noted postoperatively. This problem was solved in all instances within the following 6 months. A telephone survey with a response rate of 87% (74 patients) was undertaken in September 2007. Three children noted a minimal deficiency in strength of the injured arm in comparison to the contralateral extremity. One of these children additionally stated a minor flexion deficit of the elbow already present at the last follow-up in the outpatient clinic, which showed no progress. None of the patients had to be referred back to the outpatient clinic because of persistent problems and/or unacceptable results.