Tobias Luithle

Surgery of cavoatrial tumor thrombus in nephroblastoma: a report of the SIOP/GPOH study.

Resection of a Wilms tumor extending through the inferior vena cava into the right atrium represents a challenge to the pediatric surgeon. Exact preoperative diagnosis is essential to identify the tumor and its in travascular extension. To achieve a complete excision of the tumor cardiopulmonary bypass and hypothermia may be required. The feasibility of a complete resection is important as it guides subsequent therapy such as chemotherapy and radiation.

Perioperative Outcome of Patients with Esophageal Atresia and Tracheo-esophageal Fistula Undergoing Open Versus Thoracoscopic Surgery

INTRODUCTION Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair. PATIENTS AND METHODS We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC). RESULTS For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P>.05). CONCLUSION Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.

Laparoscopic Surgery on Upper Urinary Tract in Children Younger Than 1 Year: Technical Aspects and Functional Outcome

PURPOSE Minimally invasive procedures are increasingly important in pediatric urology. However, experience is still limited with minimally invasive operations on the upper urinary tract in infants. We analyzed 3 minimally invasive procedures (pyeloplasty, heminephroureterectomy and nephrectomy) in children younger than 1 year. MATERIALS AND METHODS We analyzed 67 children (mean +/- SD age 5.1 +/- 2.9 months) undergoing minimally invasive pyeloplasty in 26 patients (group 1), heminephroureterectomy in 18 (group 2) or nephrectomy in 23 (group 3) with regard to technical aspects, surgical outcome and complications. Preoperative and postoperative ultrasound and mercaptoacetyltriglycine renal scan were statistically evaluated in groups 1 and 2. RESULTS Mean +/- SD patient weight was 6.4 +/- 1.8 kg and mean +/- SD operative time was 113.2 +/- 41.6 minutes. Conversion to open surgery was necessary in 1 pyeloplasty. One complication (missed intraoperative bowel perforation) occurred. No blood transfusion was required in any child. After pyeloplasty there were improved tracer clearances (mercaptoacetyltriglycine scan) and improved morphologies of the pyelon (ultrasound) in all patients. In groups 1 and 2 there was no statistical difference between preoperative and postoperative partial function of the affected kidney. Mean +/- SD followup was 32.5 +/- 19.8 months. CONCLUSIONS Minimally invasive procedures on the upper urinary tract in children younger than 1 year are technically challenging, and require expertise of the surgeon and the entire team. Given these assumptions, such procedures can be safely performed with excellent functional outcomes.

Functional outcome after laparoscopic dismembered pyeloplasty in children

OBJECTIVE Laparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty. PATIENTS AND METHODS Seventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1-48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively. RESULTS Median age at operation was 20 months (1-178). Median operating time was 140 min (95-220). Mean DRF could be preserved with no significant difference (P>0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P<0.0001). Ultrasound examinations postoperatively showed a diminished grade of hydronephrosis without significance (P=0.657). CONCLUSION In terms of preservation of DRF the laparoscopic approach is as effective as open surgery. Tracer clearance is significantly improving. Operating times for laparoscopic pyeloplasty are competitive. We conclude that laparoscopic pyeloplasty requires extensive experience in laparoscopic pediatric urology but might replace the open surgical procedure as gold standard in the operative treatment of ureteropelvic junction obstruction.

Acute traumatic posterior elbow dislocation in children

Traumatic posterior dislocation of the elbow is often associated with significant morbidity and incomplete recovery. The aim of this study was to retrospectively analyse the outcome of 33 children (median age 10.8 years). Patients underwent reduction and assessment of stability under general anaesthesia. Pure dislocations (n=10) were immobilized, whereas unstable fractures (n=23) were stabilized. Refixation of ligaments was performed if stability was not achieved by fracture stabilization alone. Immobilization was continued for 26 (pure dislocations) or 35 days (associated injuries), respectively. Results were excellent (n=9) or good (n=1) after pure dislocation. Results were excellent (n=15), good (n=7) or poor (n=1) in children with associated injuries. Accurate diagnosis, concentric stable reduction of the elbow as well as stable osteosynthesis of displaced fractures are associated with good results in children with acute posterior elbow dislocations.

Single-incision laparoscopic nephroureterectomy in children of all age groups

BACKGROUND/PURPOSE The purpose of this study was to assess different surgical approaches for laparoendoscopic single-site nephroureterectomy according to weight groups. METHODS LESS nephroureterectomy was performed in 11 children. Indication for nephrectomy was a non-functioning kidney owing to vesicoureteral reflux or giant cystic dysplasia. Children below 10 kg body weight underwent LESS nephroureterectomy through an umbilical incision using one 5mm and two 3mm trocars (Manhattan technique). Patients above 10 kg were operated on using a metal multi-use single-site single port (X-Cone). RESULTS Median age at operation was 12 months (0.75-128), and median weight was 8.5 kg (3.1-67). Median operating time was 110 minutes (50-260). Eight children underwent LESS nephroureterectomy using the Manhattan-technique, and three patients were operated on with the X-Cone. All operations were carried out in a transperitoneal technique without using additional trocars. There were no complications. Recovery was uneventful in all children. CONCLUSIONS LESS nephroureterectomy for pediatric patients can be done safely and efficiently, irrespective of age and weight. However, different surgical approaches have to be considered owing to the fact that single-site ports are not available for small children and infants. Both techniques will benefit from future development of instruments and trocars more suitable for small children. The question whether LESS provides even less trauma than in conventional laparoscopy remains doubtful.

Three-dimensional laparoscopy and thoracoscopy in children and adults: A prospective clinical trial

Abstract Background: Laparoscopic procedures for children and adults already provide many advantages in two-dimensional (2D) vision. Only limited experiences exist for laparoscopic three-dimensional (3D) procedures in vivo. The aim of this prospective trial was to identify indications and limitations of the 3D-system in laparoscopic minimally invasive procedures in children and adults. Material and methods: In a prospective quality assurance for laparoscopic 3D evaluation in children and adults, a total of 53 consecutive patients (22 children, 31 adults) were included. Laparoscopic transabdominal, retroperitoneal and thoracoscopic procedures were performed. For laparoscopic 3D imaging a Camera Control Unit (CCU), 3D monitor and 3D-TIPCAM® were used. Patient data, operative procedures and image quality of the 3D system were assessed. Results: Of 53 patients, 22/53 were children and 31/53 adults with a mean age of 7.6 years (range, 10 months to 15 years) and 51.5 years (range, 18 to 79 years), respectively. 8/22 children were two years old or younger. No relevant difficulties occurred with nausea, fatigue, vertigo, eye blurring or double vision, burning eyes, visual fatigue, inconvenience of visual adaptation of 3D to 2D, or medical discomforts for the surgeons in both children and adults. Difficulties were mainly addressed to the small distance of the video endoscope and the organ tissue in small children and affected mainly image definition, resolution and eye focusing. Conclusions: Advantages of 3D over 2D were mainly considered to be of relevant benefit in adults. Subjective advantages were seen in children and adults for stereoscopic depth perception, better visualization of anatomical structures and understanding of the anatomy, as well as for complex maneuvers such as suturing.

Weight-adapted surgical approach for laparoendoscopic single-site surgery in pediatric patients using low-cost reusable instrumentation: a prospective analysis.

OBJECTIVES Laparoendoscopic single-site surgery (LESS) in pediatric patients has emerged as a viable alternative to standard laparoscopy. The aim of our investigation was to assess different surgical approaches for LESS, stratifying by weight. SUBJECTS AND METHODS From March 2010 to April 2012 LESS was performed in 42 children. Children weighing below 10 kg underwent LESS through an umbilical incision using two 3-mm trocars and one 5-mm trocar. Patients above 10 kg were operated on using a metal multiuse single-site single port (X-Cone; Karl Storz Endoskope, Tuttlingen, Germany). Conventional straight laparoscopic instruments were used in all cases. RESULTS Mean age at operation was 100 months (range, 0.25-207 months), and mean weight was 27 kg (range, 3.1-82 kg). Median operating time was 74 minutes (range, 36-300 minutes). Eighteen children underwent LESS using two 3-mm trocars and one 5-mm trocar; 1 case required two 5-mm trocars and one 10-mm trocar. Twenty-three patients were operated on with the multiuse device. All operations were carried out safely in a standard laparoscopic transperitoneal technique with full achievement of the surgical target. In none of the patients was an intraoperative complication noticed. Postoperatively two complications were noted, which resolved spontaneously. CONCLUSIONS LESS for pediatric patients can be done safely and efficiently with even less trauma than in conventional laparoscopy irrespective of age and weight. However, different surgical approaches have to be considered as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multiuse trocars and a multiuse single-site port were used with conventional laparoscopic instruments.

Laparoscopically Guided External Transanastomotic Stenting in Dismembered Pyeloplasty: A Safe Technique

OBJECTIVE To describe a technique for insertion of external transanastomotic stents during laparoscopic dismembered pyeloplasty in children of all age-groups. To analyze stent-associated complications and changes in differential renal function (DRF). PATIENTS AND METHODS A retrospective study was performed of all patients up to 18 years of age undergoing laparoscopic pyeloplasty at our institution between March 2004 and December 2013. We analyzed patients in whom an external transanastomotic stent was placed using a specially constructed semicircular spear. Medical records were reviewed for stent-associated complications such as bleeding, stent dislocation, stent obstruction, and urinary tract infection. Additionally required secondary surgical procedures and changes in DRF were assessed. RESULTS A total of 150 patients (155 renal units [RU]) were included in the study, with a median patient age of 22 months (range, 1-214). Stents were removed after a median time of 7 days (range, 3-21). Stent-associated complications were observed in a total of 11 patients (12 RU), consisting of stent dislocations (6 RU), stent obstructions (3 RU), and persistent percutaneous leakage along the stent (1 RU) or after stent removal (2 RU). Stent-associated complications required a secondary surgical procedure in 4 RU. Neither significant blood loss nor urinary tract infection was associated with external transanastomotic stent placement. DRF did not change significantly after the procedure. CONCLUSION External transanastomotic stenting during laparoscopic dismembered pyeloplasty using a specially constructed semicircular spear is a safe technique associated with a low complication rate and only rarely requires secondary surgical procedures for stent-related complications. This technique makes an additional anesthesia for stent removal unnecessary, as it is required for internal urinary diversion.