Roger D. Cohen

Primary Laparoscopic-Assisted Endorectal Colon Pull-Through for Hirschsprung’s Disease: A New Gold Standard

OBJECTIVE To describe the surgical technique and early clinical results after a one-stage laparoscopic-assisted endorectal colon pull-through for Hirschsprungs disease. SUMMARY BACKGROUND DATA Recent trends in surgery for Hirschsprungs disease have been toward earlier repair and fewer surgical stages. A one-stage pull-through for Hirschsprungs disease avoids the additional anesthesia, surgery, and complications of a colostomy. A laparoscopic-assisted approach diminishes surgical trauma to the peritoneal cavity. METHODS The technique uses four small abdominal ports. The transition zone is initially identified by seromuscular biopsies obtained laparoscopically. A colon pedicle preserving the marginal artery is fashioned endoscopically. The rectal mobilization is performed transanally using an endorectal sleeve technique. The anastomosis is performed transanally 1 cm above the dentate line. This report discusses the outcome of primary laparoscopic pull-through in 80 patients performed at six pediatric surgery centers over the past 5 years. RESULTS The age at surgery ranged from 3 days to 96 months. The average length of the surgical procedure was 2.5 hours. Almost all of the patients passed stool and flatus within 24 hours of surgery. The average time for discharge after surgery was 3.7 days. All 80 patients are currently alive and well. Most of the children are too young to evaluate for fecal continence, but 18 of the older children have been reported to be continent. CONCLUSION Laparoscopic-assisted colon pull-through appears to reduce perioperative complications and postoperative recovery time dramatically. The technique is quickly learned and has been performed in multiple centers with consistently good results.

Anatomic observations and etiologic and surgical considerations in choledochal cyst.

Twenty-five operative and postoperative cholangiograms in children with choledochal cysts indicated an intimate relationship between these cysts and anomalous pancreatico-biliary ductal junction. In all of these patients the distal main pancreatic duct (MPD) is excluded from the sphinctor of Oddi mechanism and free reflux of pancreatic juice up the biliary tree occurs. This leads to chronic cholangitis, which is presumed to be responsible for the formation of the choledochal cysts. Abrupt and intense exposure of the common bile duct (CBD) to pancreatic reflux may cause perforation and bile peritonitis. Long-standing exposure may induce malignant transformation in the choledochal cyst. Total cyst excision and separation of the biliary system from exposure to pancreatic reflux is suggested as the procedure of choice. Long-term results and metabolic and digestive consequences of this operation are yet to be determined.

Esophageal bougienage technique for coin ingestion in children

An analysis was performed of 46 consecutive children who received esophageal bougienage for an ingested coin lodged in the esophagus. All patients met the following clinical criteria necessary for performance of this procedure: an acutely ingested single coin, radiographically localized in the esophagus; no previous history of an esophageal disease process, surgical procedure performed or foreign body removed; and no respiratory compromise upon physical examination. All coins were successfully advanced distally into the stomach after one pass of the bougie dilator. No complications were noted during or after performance of any procedure. Esophageal bougienage is a safe and effective method used to dislodge and pass an ingested coin from the esophagus when criteria for its performance are adhered to rigidly.

Plexiform neurofibromas in childhood

Abstract Sixteen cases of plexiform neurofibroma occurring in childhood have been discussed. Of lesions in the trunk or extremities, only two required multiple procedures, including a below-the-knee amputation. All patients are free of tumor at present, though they carry other stigmata of Von Recklinghausens disease. Of the seven children with cervicothoracic lesions, however, one is dead, two have significant neurologic deficit (severe quadriparesis, 70% arm weakness), and none is free of tumor. One has permanent tracheostomy and three have gross tumor extending to their vertebral column or skull without longtract signs as yet. Though histologically benign, plexiform neurofibroma of the neck and thorax in children must be considered a progressive crippling disease that is extremely difficult to control surgically and carries a grave prognosis.

Steroids and bag and mask ventilation in the treatment of acute epiglottitis

A non-instrumentation treatment protocol for acute epiglottitis that features the use of dexamethasone to reduce edema and positive pressure ventilation by bag and mark to support ventilation, if needed, has been used in 40 cases, 1974--1977, with no mortality. The presence of the airway specialist (pediatric surgeon) in the Intensive Care Unit with the patient further assured the airway. The importance of having a protocol in place that is workable for the specific local circumstances of each institution is emphasized.

Glucose malabsorption in Hirschprung's disease: A case report

This is a report of a new case of glucose intolerance that developed in a young child with Hirschprungs disease.