Salmai Turial

Pectus excavatum: history, hypotheses and treatment options

Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.

Laparoscopic inguinal hernia repair does not impair testicular perfusion.

BACKGROUND Laparoscopic inguinal hernia repair techniques close the internal ring with a suture. Concern has been raised whether or not the testicular vessels are compromised with this technique. This study was undertaken to evaluate pre- and postoperative testicular perfusion and to compare it with healthy controls. PATIENTS AND METHOD Sixty-five boys (aged 6 weeks to 11 years; median, 1.4 years) with unilateral (n = 52) or bilateral (n = 13) inguinal hernias were treated laparoscopically. Testicular perfusion was measured using a recently developed neuromonitoring device (O2C; LEA Medizintechnik GmbH, Giessen, Germany), which combines light spectroscopy and laser Doppler technique. An optical probe was placed on the surface of each scrotal pouch for measurements at 2 depths (2 and 8 mm). Measurements involved oxygen (O(2)) saturation at the venous end of capillaries, the amount of hemoglobin within microvessels, the blood flow within microcirculation, and the velocity of the blood in microcirculation. Measurements were conducted before and after anesthesia, before and after surgery, and 6 weeks later. Twenty-one healthy boys of similar ages served as controls. RESULTS Measurements at 2-mm depth were unreliable. At 8-mm depth, the oxygen saturation of hemoglobin was between 62% and 75% (hypoxia would be <10%). The relative blood flow was between 160 to 235 arbitrary units, better than in healthy awake controls. Values were solely influenced by the administered fraction of inspired oxygen. Relative hemoglobin volume of the testes and blood flow velocity remained unchanged after surgery. Values were also normal when measured during early and long-term follow-up. CONCLUSION Laparoscopic inguinal hernia repair using suture closure of the internal inguinal ring does not impair testicular perfusion.

Decline in Infantile Hypertrophic Pyloric Stenosis in Germany in 2000–2008

BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence. METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000–2008. RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67–5.33]) to 2008 (2.0175/1000 LB [1.74–3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54–1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285–0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS. CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

The Use of a Plastic Bag From a Drain Package Instead of an Endobag in Children: A Safe, Effective, and Economical Alternative

Purpose. The standard endobags require large trocars; because the authors routinely use 2- to 5-mm instruments, they were looking for complementary specimen retrieval device alternatives. For this purpose, they recently used a plastic bag from a drain package to exteriorize abdominal masses during laparoscopy in children. Method. A plastic bag from a drain package—the innermost cover—was placed into the abdominal cavity trough a 5-mm trocar. The plastic bag was intraabdominally uncoiled with 2-mm instruments. Bag plus specimen were exteriorized via the umbilicus. Results. During the last 4 years, the authors have removed various specimens in 135 cases. The specimens were successfully retrieved in all cases. No rupture of the bag or slippage was observed. One commercial endobag costs the same as 359 “plastic bags.” Conclusion. Based on the authors’ experience in pediatric laparoscopy, they feel that the use of plastic bags for retrieval of abdominal specimens is feasible, safe, and economical.

Microlaparoscopic-assisted gastrostomy in children: early experiences with our technique.

INTRODUCTION The aim of this prospective study was to evaluate the feasibility and safety of a new technique for microlaparoscopic-assisted gastrostomy (MAG) in children and infants by using a 1.9-mm scope only. In this paper, we report our early experiences with this method. MATERIALS AND METHODS In a prospective study, MAG was performed on 12 children (7 boys and 5 girls) after a primary percutaneous endoscopic gastrostomy procedure was considered not feasible or unsafe. The median patient age at the time of surgery was 1.2 years (range, 4 months to 4 years). A 1.7- or 1.9-mm 0-degree scope was introduced at the umbilicus. A 5-mm port was placed over the stomach at the designated site for the tube placement. The stomach was grasped and exteriorized. The gastrostomy was opened, and a balloon gastrostomy tube was placed. RESULTS In 12 children, the procedure was successfully completed without conversions. Mean operative time was 19 minutes (range, 13-35). No intraoperative complications occurred. Feeds were instituted 5 hours postoperatively and quickly advanced the following day in 11 of 12 children. The procedure may be performed as day surgery. CONCLUSIONS In our opinion, MAG is a feasible, safe procedure in children. Technically, it is a simple method, particularly in cases where percutaneous tube placement is not feasible. It combines the advantages of microlaparoscopy and open surgery. It is easy to perform in children and allows a primary gastrostomy tube placement. Parents and nursing staff also seem satisfied.

Microlaparoscopic Hernia Repair in Children Initial Experiences

Introduction. This study reports the authors’ experience with the exclusive use of 2-mm instrument sets and small diameter scopes in 100 children undergoing microlaparoscopic herniorrhaphy. Method. This prospective study was designed as a pilot feasibility study; all data related to patients and procedures were prospectively collected. A pneumoperitoneum was established, and 1.7 to 2 mm 0° or 30° scopes were introduced for visualization. Exclusively 2-mm instruments were used. Results. This study included 100 children (aged 15 days to 11 years, median age 2.3 years) undergoing microlaparoscopic hernia repair. A total of 140 hernias were treated. The average operative time for the microlaparoscopically experienced surgeon was 16 minutes for bilateral inguinal hernia and 12 minutes for unilateral hernias. All procedures were completed microlaparoscopically. Hernia recurrence was observed in 2 patients.Conclusion. Based on the authors’ early experience, it is found that microlaparoscopic hernia repair in children seems to be a safe and feasible procedure.

Correlation of maternal age and migration on IHPS epidemiology in Germany 2000-2008.

A decline in the incidence of infantile hypertrophic pyloric stenosis (IHPS) was recently reported in Sweden, the US, Denmark, Scotland, and Germany. Data to explain this phenomenon, however, are scarce. Given our previous epidemiologic data showing a decline in the incidence of IHPS, we collected data on maternal age and history of migration from regional administrative centers to obtain data that might support an explanation for our previous findings. We examined the correlation between these factors and the incidence of IHPS. Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes) and population data from federal state governments. We obtained the numbers of IHPS (ICD-10 code 40.0) and live births in each federal state for the period 2000-2008. Further data were collected from federal state administrative agencies on age of the mother at the birth of their first child and history of migration for all mothers at first birth. There were significant differences in the regional distribution of both variables and the variability of these factors over time. Average maternal age and the percentage of mothers with a history of migration showed a negative correlation with the regional incidence of infantile hypertrophic pyloric stenosis. Conclusion: The wide variation in the incidence of infantile hypertrophic pyloric stenosis over time and for different regions is significantly inversely correlated with rising maternal age and the percentage of mothers with a history of migration.

Microlaparoscopic Cholecystectomy with an Unorthodox Scope Position

PURPOSE We report our initial experiences with microlaparoscopic cholecystectomy (MLCE) in children using a 2.4-mm mini-scope placed to the right of the umbilicus. The umbilicus was used as the working trocar for large-diameter instruments. METHODS The mini-scope was inserted 2-3 cm to the right to the umbilicus and slightly above the umbilical line. A miniport for the 2-mm grasper was inserted laterally through the right abdominal wall, and a 5-mm working trocar was inserted infra-umbilically. The three-angle principle of laparoscopic instrumentation remained, as the trocar positions were merely shifted to the right side of the abdominal wall. With the patient in the supine position, the surgeon stood on the left side of the patient, facing the monitor. RESULTS MLCE was successfully performed in 12 children (average age: 15 years, average body weight: 46.4 kg). In two cases, the optic trocar was repositioned one cm laterally, because the initial trocar position was too close to the umbilicus and was colliding with the 5-mm instruments. The view at the cystohepatic triangle was sufficient. There were no specific complications due to the rearranged trocar positions or the use of a mini-scope. It was possible to displace the scope out of the umbilical area without compromising the superior cosmesis allowed by using only miniports. CONCLUSION Based on our early experiences, MLCE is safe and feasible. This technique helps reduce the access trauma and operative time while allowing for superior cosmesis.

A Microlaparoscopically Assisted Pull-Through Procedure for Hirschsprung's Disease: Initial Experiences

PURPOSE The purpose of this prospective study was to evaluate the efficiency, feasibility, and surgical outcomes of microlaparoscopy-assisted pull-through (MAPT) for Hirschsprungs disease. METHODS Starting in 2005, pull-through procedures for Hirschsprungs disease were performed exclusively using 2-mm instruments and miniscopes (microlaparoscopy). Three miniports were inserted laterally in the right abdominal wall in one line, with the miniscope at the level of the umbilicus and the working trocars cranially/caudally of the scope. The left colon was dissected, and transanal pull-through was performed. RESULTS MAPT was performed in 16 children (10 boys and 6 girls; average age: 5.7 months). Six patients had previous abdominal surgeries. A 1.9-mm cystoscope or a 2.4-mm arthroscope was used in the first 5 cases. In the remainder, a recently developed 2.4-mm miniscope was used for visualization. The length of the resected colon segment was up to the left colonic flexur in 5 children, up to the middle of the descending colon in 4 cases and up to the sigmoid-descending segment in 7 children. The average operation time was 185 minutes (range: 120-330 minutes). The only intraoperative complication that occurred was an injury of the right iliac vein by inadvertent slippage of an electrocautery hook requiring laparotomy. At follow-up, 80% of the parents were unable to identify the scars after microlaparoscopy. CONCLUSION MAPT is a safe and practical procedure regardless of age or previous surgery.

Cartilage Histology in Chest Wall Deformities

Even if pectus excavatum and pectus carinatum represent the most frequent chest wall deformities their formal pathogenesis is still poorly understood. Research results regarding the pathophysiology and the cellular pathomechanisms of these disorders remain inconsistent and contradictory. The present contribution focuses on the recent state of pathophysiological knowledge, with summary and critical discussion of leading pathological concepts. Based on a short history of these entities and the different pathophysiological concepts we have reviewed leading studies on the formal pathogenesis of pectus excavatum and pectus carinatum. Furthermore, histological, immunohistological and ultrastructural changes in sterno-costal cartilage from pectus excavatum and pectus carinatum are presented. The histomorphological features of rib cartilage from these lesions are characterized by markedly degenerative changes of the chondrocytes and the extracellular matrix. Research at our Centre has demonstrated ultrastructural changes which open up innovative perspectives for a new pathophysiological concept which could explain the cartilage damage. Furthermore, immunohistological results are presented regarding proliferative and synthetic activity of chondrocytes within pectus excavatum. Based on the structural and immunohistological changes in pectus excavatum and pectus carinatum the need for comprehensive morphological analysis needs to be discussed, including comparative studies with normal rib cartilage and fetal rib cartilage from different developmental stages.