Whitney McBride

Primary omental infarct: conservative vs operative management in the era of ultrasound, computerized tomography, and laparoscopy.

PURPOSE Primary omental infarct is a rare condition in children. The preoperative diagnosis can be accurately accomplished using ultrasound (US) and computerized tomography (CT). This study aimed to elucidate the efficacy of conservative vs operative management. METHODS Cases of omental infarction in children diagnosed preoperatively in our institution since laparoscopy became the standard of care were reviewed. RESULTS Ten cases of omental infarction in children were treated. There were 6 males and 4 females (age, 5-14 years). The diagnosis was made preoperatively by CT in all cases; in 2 cases, US was also diagnostic. Conservative nonoperative management was successful in 4 cases, and laparoscopic omentectomy and appendectomy done in the other 6. There was no mortality. All children recovered uneventfully. Average hospital stay was 4 days for patients treated nonoperatively. Average postoperative stay was 2 days for children treated with laparoscopy. Three patients initially treated conservatively had surgery because of intractable pain. The preoperative stay was 3 days in these patients. CONCLUSIONS Children with omental infarct can be treated conservatively, and a short trial period is warranted. The indications for surgery are uncertain diagnosis, intractable relentless pain, and persistent peritoneal findings. Children treated with laparoscopy have a shorter length of stay and decreased use of narcotics.

Laparoscopic placement of peritoneal dialysis catheters in children

BACKGROUND Peritoneal dialysis (PD) is preferred over hemodialysis. The aim of this study was to evaluate our experience with laparoscopic PD catheter placement and omentectomy in children. METHODS We reviewed all children (N = 21) who underwent laparoscopic placement of PD catheters and omentectomy. Ages ranged from 3 months to 16 years. Five children had previous major abdominal surgery and required extensive lysis of adhesions. During the same intervention, other surgical procedures were performed using laparoscopy or open technique, including umbilical hernia repair in 3, bilateral inguinal hernia repair in 3, ventral hernia repair in 2, gastrostomy in 4, kidney biopsy in 2, and cholecystectomy in 1. RESULTS Thirteen children received successful kidney transplantation and no longer needed dialysis. Two children still have functioning PD catheters. One patient developed membrane failure and was converted to hemodialysis. Four patients recovered enough renal function and no longer need dialysis. There were no complications related to the laparoscopic procedure. CONCLUSION Laparoscopy is ideal for PD catheter placement. It facilitates omentectomy, and it allows for the catheter to be placed in the proper position under direct vision and for lysis of adhesions to increase peritoneal surface. Other abdominal procedures can be performed laparoscopically at the same time.

Correlation of complex ascites with intestinal gangrene and perforation in neonates with necrotizing enterocolitis.

BACKGROUND/PURPOSE The purpose of this study was to determine whether a correlation exists between the finding of complex ascites on ultrasound (US) and the presence of intestinal perforation or gangrene in neonates with complicated necrotizing enterocolitis (NEC). METHODS Charts of neonates with NEC (n = 76) whose care involved consultations with the pediatric surgery service between 2005 and 2008 were reviewed. Twenty-three babies with NEC without free air had a bedside abdominal US. Neonates with pneumoperitoneum were excluded from the study because this was an absolute indication for surgical intervention. RESULTS Twelve of the 23 neonates who had a bedside abdominal US were found to have ascites with debris or complex ascites. One of these 12 patients improved with medical management, and the ascites resolved. One infant with complex ascites had an initial laparotomy that revealed extensive bowel necrosis and gangrene that required intestinal resection and ostomy creation. This infant survived and is currently doing well. Ten patients were critically ill and were managed with bedside peritoneal drainage. Of those, 7 had drainage of intestinal contents after placement of the drain. Two of the babies who had a drain placed for complex ascites subsequently died of progressive disease. Five neonates with ascites with debris improved after peritoneal drainage and were subsequently subjected to laparotomy. All had gangrene with intestinal perforation. Three infants with complex ascites and intestinal contents were not observed during the initial peritoneal drainage. They improved after peritoneal drainage and had laparotomy. Free intestinal perforation was not demonstrated. The 3 infants in this group survived. CONCLUSIONS The presence of complex ascites with debris correlated well with intestinal gangrene or perforation. This correlation may also be a predictor of mortality. Neonates with complicated NEC without clear indication for surgical intervention would benefit from bedside abdominal US evaluation.

Repair of long gap esophageal atresia without anastomosis

BACKGROUND/PURPOSE Repair of long gap esophageal atresia represents a challenge. Several different techniques may be used. We describe 5 cases of long gap esophageal atresia managed successfully with suture approximation without anastomosis. METHODS Retrospective review identified 5 newborns (4 males; 1 female) with long gap esophageal atresia treated with suture approximation and subsequent endoscopic and fluoroscopic placement of string for guided dilatations. Three babies had esophageal atresia without fistula, and 2 had the common type with proximal atresia and distal tracheoesophageal fistula. The babies with pure esophageal atresia had delayed repair, and those with the common type had repair 2 days after birth. All had a gastrostomy for feedings. RESULTS All 5 babies recovered uneventfully. Three babies had spontaneous fistulization that allowed easy placement of guide wire and string. Two other babies required endoscopic and fluoroscopic combined fistula creation bypassing a long needle from the upper pouch to the lower one. Initially, all had string-guided dilatations that were subsequently converted to balloon dilatations. All babies had a functioning esophagus and did not need any further surgical intervention. An average of 8 postoperative dilatations were needed. CONCLUSIONS The babys own functional esophagus is superior to any esophageal replacement. Familiarity with different techniques to preserve it is therefore important. Suture approximation without anastomosis is a safe technique that can be applied to long gap esophageal atresia. The downside of this technique is a prolonged hospital stay, multiple dilatations, prolonged fasting, and therapy to learn to eat orally.

Laparoscopy and complicated meckel diverticulum in children.

Background and Objectives: Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy. Methods: A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum. Results: Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications. Conclusions: Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.

Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature.

BACKGROUND Traumatic abdominal wall hernia (TAWH) is defined as herniation through a disrupted portion of musculature/fascia without skin penetration or history of prior hernia. In children, TAWH is a rare injury. OBJECTIVE The objectives of this study were to report our experience with different management strategies of TAWH in children and to determine the utility of laparoscopy. DESIGN/METHOD A retrospective chart review of all children treated by pediatric surgery at our institution for TAWH in a 5year interval was performed. Data were collected on mechanism of injury, initial patient presentation, surgical management, and outcomes. RESULTS We present 5 cases of traumatic abdominal wall hernia; 3 were managed using laparoscopic assistance. One patient was managed nonoperatively. All patients recovered without complications and were asymptomatic on follow up. CONCLUSION Traumatic abdominal wall hernias require a high index of suspicion in the cases of blunt abdominal trauma. Laparoscopy is useful mainly as a diagnostic modality, both to evaluate the hernia and associated injuries to intraabdominal structures. Its use may facilitate repair through a smaller incision. Conservative management of TAWH may be appropriate in select cases where there is a low risk of bowel strangulation.

Extraperitoneal Closure of Persistent Gastrocutaneous Fistula in Children

Extraperitoneal closure of gastrocutaneous fistula can be safe and effective. This approach can allow for rapid resumption of feeding and a shortened length of stay.

Multimodality imaging of an appendiceal intussusception

Appendiceal intussusception is a rare entity. The majority of cases reported in the literature address surgical and colonoscopic approaches to treatment of the condition. The existing radiologic literature largely describes the sonographic and double-contrast enema findings of appendiceal intussusception. We present a case of appendiceal intussusception and describe the air-contrast enema, sonographic and CT findings.

Laparoscopic Surgery for Acute Appendicitis in Children With Cancer.

Introduction: Abdominal pain during cancer chemotherapy may be caused by medical or surgical conditions. A retrospective review of 5 children with cancer who had appendicitis while receiving chemotherapy was performed. Case Descriptions: Three had acute lymphoblastic leukemia, and 1 each had T-cell lymphoblastic lymphoma and rhabdomyosarcoma. Two of the patients had a Pediatric Appendectomy Score of 6, and 1 each had a score of 7, 5, and 2. All had evidence of appendicitis on computed tomography. Laparoscopic appendectomy was performed without any perioperative complication. Discussion: Appendicitis is an important diagnosis in children with cancer, and laparoscopic appendectomy is safe and the procedure of choice.

International teleconsultation on conjoined twins leading to a successful separation: a case report:

Conjoined twins are identical twins that have incompletely separated in utero. The prognosis for conjoined twins is poor and management in a skilled tertiary care centre is paramount for definitive care. We describe our experience with a telemedical consultation on conjoined twins in The Dominican Republic from our eHealth centre in Valhalla, NY. The patients were two month old, female, pygopagus conjoined twins. A multidisciplinary teleconference was initiated with the patients, their family, the referring paediatrician and our team. Based on this teleconsultation, the team felt as though the twins may be amenable to a surgical separation. They presented to our centre in Valhalla, NY, for a detailed physical examination and series of imaging studies. Soon after, the patients underwent a successful 21 h separation procedure and were discharged 12 weeks later. To our knowledge, this is one of the first reports of an international teleconsultation leading to a successful conjoined twin separation procedure.