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Laparoscopic appendectomies in children: Are there advantages?
ABSTRACTS
button and the rare incidence of accidental dislodgement made it immediately popular. Although the manufacturers still recommend that the button only be used as a replacement tube, we began to use it as the appliance of choice at the time of the gastrostomy operation, ie, a primary gastrostomy button (PGB). In contrast to the standard Stamm gastrostomy technique, the PGB is placed through a vertical midline incision and the appliance is positioned in the cephalad portion of the incision. Sixty-five PGBs have been performed in the past 24 months in children ranging from 3 kg to 30 kg. The most common indications for gastrostomy were severe neurological impairment (38%) cystic fibrosis (14%). central nervous system or head and neck malignancies (12%), and renal failure (9%). Ninety percent of the PGBs are still in place, functioning well. One child developed persistent cellulitis and drainage with each episode of chemotherapy induced neutropenia and had his PGB removed. Another PGB was accidently dislodged by a toddler and was successfully replaced without problems. The remaining PGB removals were performed after treatments or the disease states had run their course. A persistent gastrocutaneous fistula resulted in one of the six patients whose PGB was removed (16.6%). PGB is a safe technique with a high degree of parental and patient satisfaction, and is now our gastrostomy tube of choice. The Modified Janeway Gastrostomy: A Superior Route of Enteral Access J.L. Meller, D.S. Loefi K. W Reichard, M. Kerschner, J.R. Hall, H.M. Reyes, Cook County Hospital, The University of Illinois and RushPresbyterinn St Luke’s Medical Center, Chicago, IL
The association between Stamm Gastrostomy (SG) and gastroesophageal reflux (GER) in the neurologically impaired (NI) child is well documented and thought to be related to anterior gastropexy (AG). Data obtained from animal studies appear to indicate that a modified Janewaygastrostomy (MJG), fashioning the gastric tube from the greater curvature of the stomach eliminates the AG, lessening the risk of GER, and obviates the need for a chronically indwelling catheter. A prospective clinical evaluation of MJG was undertaken in 27 of 104 NI patients referred for enteral access who were found to be free of GER with technetium (TC-99m) GER scanning and 24hour pH monitoring between 1985 and 1991. Concomitant pyloroplasty was done in 3 of 27 patients with delayed gastric emptying. The mean age of the patients was 9 years (3 mo to 25 yr) with an average hospital stay of 15 days (range, 6 to 30 days). Twenty-two (81.5%) patients were available for follow-up of 1 month to 5 years. Eighteen of 27 (70.3%) patients showed no evidence of GER while 2 patients (8.4%) with mild GER responded to medical management. There was one early complication of wound infection and two late complications related to the stoma. Two deaths occurred in this series: an early death due to pneumonia unrelated to GER and 1 late death secondary to progression of neurological disease. In conclusion, MJG seems to offer several advantages to SG in the NI patient without documented GER: (1) less documented postoperative GER; (2) eliminates the need for an indwelling catheter; (3) minimal early and late postoperative complications; and (4) eliminates the need for a prophylactic Nissen fundoplication. Laparoscopic Appendectomies in Children: Are There Advantages? F. Schier, .I. Waldschmidt, L. Proafio, University Medical Center Steglitz, Berlin, Germany
Minimally invasive surgery is revolutionizing the way we think about a variety of intraabdominal interventions. Although advantages of certain laparoscopic procedures (eg, cholecystectomy) are
FROM POSTER SESSIONS
now well established in both children and adults, the superiority of other “dosed” procedures (eg, appendectomy) remains controversial. During a 12-month period 38 selected laparoscopic appendectomies (LA) were performed in children ranging from 6 to 15 years (median, 10.7 years). The majority were girls (23 children; 61%) with recurrent bouts of right lower quadrant pain where the diagnosis was not straightfonvard. In obvious “classic” acute appendicitis the conventional appendectomy (CA) was performed. For LA we used two lower abdominal incisions and an umbilical incision, measuring 0.5 to 1 cm each. The average operative time for LA was 55 minutes, compared to 39 minutes for a conventional appendectomy by the same team. Two LA were converted to an open procedure because of bleeding. Both occurred early in our experience. There was one wound infection and one hematoma. Children commonly complained about right shoulder pain up to 3 days. A transient temperature elevation during the first 2 postoperative days was common. Compared to conventional appendectomies we observed no difference in the need for pain medication, return to regular diet or length in postoperative stay. Although advantageous in older patients, the superiority of LA over CA could not be demonstrated in the younger children since the operative trauma of both procedures in this group was identical. Intraabdominal visualization was excellent. The procedure was especially useful as a diagnostic tool in youngsters with ill defined pain. This series establishes the feasibility and safety of LA in children. Further experience is necessary to define its merits and
Development of an Animal Model for lleoanal Pouchitis Stuart R. Lacey, Steven Lichtman, University of North Carolina School of Medicine, Chapel Hill, NC
Pouchitis is a serious common complication of construction of an ileal reservoir (pouch) following colectomy and ileoanal pullthrough. Therapy has been empirically based because the etiology remains unclear. Bacterial overgrowth probably plays a role but does not explain the higher incidence in patients with ulcerative colitis compared to familial polyposis. The absence of an animal model has been a major impediment to pouchitis research. We have developed a rat model of pouchitis analogous to human pouchitis in terms of presentation, anatomy and histological features. Lewis rats were selected because they have been utilized successfully in small bowel bacterial overgrowth models. Under Ketaminei ether anesthesia we performed ileal pouch formation restoring enteric continuity with end-to-end anastomosis to the rectum. High mortality from pancreatits associated with colectomy led us to bypass the colon with proximal and distal mucus fistulas instead. Control animals underwent the same operation but no pouch was created. Autopsies were performed 2 to 4 months following surgery. Inflammation of the pouch and small bowel was histologically scored by the method of Moskowitz (range, 0 to 6, with 0 being normal). Samples of liver, spleen, peritoneum, and blood were obtained for culture. Serum antipeptiglycan antibodies were measured by a standard ELISA assay. All 6 experimental rats with pouches developed moderate to severe inflammation of the pouch with a Moskowitz score of 4.8 + 1.2 (mean 2 SD; range. 3 to 6). Inflammation was limited to the pouch. Antipeptiglycan antibodies were elevated in all 6 rats, a finding similar to that found in rats with surgical creation of jejunal self-filling blind loops (small bowel bacterial growth). Control animals showed no inflammatory changes and antipeptiglycan antibodies were normal. Cultures of liver, spleen, peritoneum, and blood were negative in both groups.
button and the rare incidence of accidental dislodgement made it immediately popular. Although the manufacturers still recommend that the button only be used as a replacement tube, we began to use it as the appliance of choice at the time of the gastrostomy operation, ie, a primary gastrostomy button (PGB). In contrast to the standard Stamm gastrostomy technique, the PGB is placed through a vertical midline incision and the appliance is positioned in the cephalad portion of the incision. Sixty-five PGBs have been performed in the past 24 months in children ranging from 3 kg to 30 kg. The most common indications for gastrostomy were severe neurological impairment (38%) cystic fibrosis (14%). central nervous system or head and neck malignancies (12%), and renal failure (9%). Ninety percent of the PGBs are still in place, functioning well. One child developed persistent cellulitis and drainage with each episode of chemotherapy induced neutropenia and had his PGB removed. Another PGB was accidently dislodged by a toddler and was successfully replaced without problems. The remaining PGB removals were performed after treatments or the disease states had run their course. A persistent gastrocutaneous fistula resulted in one of the six patients whose PGB was removed (16.6%). PGB is a safe technique with a high degree of parental and patient satisfaction, and is now our gastrostomy tube of choice. The Modified Janeway Gastrostomy: A Superior Route of Enteral Access J.L. Meller, D.S. Loefi K. W Reichard, M. Kerschner, J.R. Hall, H.M. Reyes, Cook County Hospital, The University of Illinois and RushPresbyterinn St Luke’s Medical Center, Chicago, IL
The association between Stamm Gastrostomy (SG) and gastroesophageal reflux (GER) in the neurologically impaired (NI) child is well documented and thought to be related to anterior gastropexy (AG). Data obtained from animal studies appear to indicate that a modified Janewaygastrostomy (MJG), fashioning the gastric tube from the greater curvature of the stomach eliminates the AG, lessening the risk of GER, and obviates the need for a chronically indwelling catheter. A prospective clinical evaluation of MJG was undertaken in 27 of 104 NI patients referred for enteral access who were found to be free of GER with technetium (TC-99m) GER scanning and 24hour pH monitoring between 1985 and 1991. Concomitant pyloroplasty was done in 3 of 27 patients with delayed gastric emptying. The mean age of the patients was 9 years (3 mo to 25 yr) with an average hospital stay of 15 days (range, 6 to 30 days). Twenty-two (81.5%) patients were available for follow-up of 1 month to 5 years. Eighteen of 27 (70.3%) patients showed no evidence of GER while 2 patients (8.4%) with mild GER responded to medical management. There was one early complication of wound infection and two late complications related to the stoma. Two deaths occurred in this series: an early death due to pneumonia unrelated to GER and 1 late death secondary to progression of neurological disease. In conclusion, MJG seems to offer several advantages to SG in the NI patient without documented GER: (1) less documented postoperative GER; (2) eliminates the need for an indwelling catheter; (3) minimal early and late postoperative complications; and (4) eliminates the need for a prophylactic Nissen fundoplication. Laparoscopic Appendectomies in Children: Are There Advantages? F. Schier, .I. Waldschmidt, L. Proafio, University Medical Center Steglitz, Berlin, Germany
Minimally invasive surgery is revolutionizing the way we think about a variety of intraabdominal interventions. Although advantages of certain laparoscopic procedures (eg, cholecystectomy) are
FROM POSTER SESSIONS
now well established in both children and adults, the superiority of other “dosed” procedures (eg, appendectomy) remains controversial. During a 12-month period 38 selected laparoscopic appendectomies (LA) were performed in children ranging from 6 to 15 years (median, 10.7 years). The majority were girls (23 children; 61%) with recurrent bouts of right lower quadrant pain where the diagnosis was not straightfonvard. In obvious “classic” acute appendicitis the conventional appendectomy (CA) was performed. For LA we used two lower abdominal incisions and an umbilical incision, measuring 0.5 to 1 cm each. The average operative time for LA was 55 minutes, compared to 39 minutes for a conventional appendectomy by the same team. Two LA were converted to an open procedure because of bleeding. Both occurred early in our experience. There was one wound infection and one hematoma. Children commonly complained about right shoulder pain up to 3 days. A transient temperature elevation during the first 2 postoperative days was common. Compared to conventional appendectomies we observed no difference in the need for pain medication, return to regular diet or length in postoperative stay. Although advantageous in older patients, the superiority of LA over CA could not be demonstrated in the younger children since the operative trauma of both procedures in this group was identical. Intraabdominal visualization was excellent. The procedure was especially useful as a diagnostic tool in youngsters with ill defined pain. This series establishes the feasibility and safety of LA in children. Further experience is necessary to define its merits and
Development of an Animal Model for lleoanal Pouchitis Stuart R. Lacey, Steven Lichtman, University of North Carolina School of Medicine, Chapel Hill, NC
Pouchitis is a serious common complication of construction of an ileal reservoir (pouch) following colectomy and ileoanal pullthrough. Therapy has been empirically based because the etiology remains unclear. Bacterial overgrowth probably plays a role but does not explain the higher incidence in patients with ulcerative colitis compared to familial polyposis. The absence of an animal model has been a major impediment to pouchitis research. We have developed a rat model of pouchitis analogous to human pouchitis in terms of presentation, anatomy and histological features. Lewis rats were selected because they have been utilized successfully in small bowel bacterial overgrowth models. Under Ketaminei ether anesthesia we performed ileal pouch formation restoring enteric continuity with end-to-end anastomosis to the rectum. High mortality from pancreatits associated with colectomy led us to bypass the colon with proximal and distal mucus fistulas instead. Control animals underwent the same operation but no pouch was created. Autopsies were performed 2 to 4 months following surgery. Inflammation of the pouch and small bowel was histologically scored by the method of Moskowitz (range, 0 to 6, with 0 being normal). Samples of liver, spleen, peritoneum, and blood were obtained for culture. Serum antipeptiglycan antibodies were measured by a standard ELISA assay. All 6 experimental rats with pouches developed moderate to severe inflammation of the pouch with a Moskowitz score of 4.8 + 1.2 (mean 2 SD; range. 3 to 6). Inflammation was limited to the pouch. Antipeptiglycan antibodies were elevated in all 6 rats, a finding similar to that found in rats with surgical creation of jejunal self-filling blind loops (small bowel bacterial growth). Control animals showed no inflammatory changes and antipeptiglycan antibodies were normal. Cultures of liver, spleen, peritoneum, and blood were negative in both groups.