Minimally invasive repair of pectus excavatum—the Nuss procedure. A European multicentre study

INTERNATIONAL ABSTRACTS

introducer was developed to elevate the sternum before bar insertion. A stabilizing bar was created to minimize bar displacement. The duration of sternal bracing has been increased from 2 to 4 years in selected patients. There were no deaths, no cardiac perforations, and no cases of thoracic chondrodystrophy. Pneumothorax with spontaneous resolution occurred in 52% of the patients, with 1.2% requiring simple aspiration and 1.5% chest tube drainage. This complication has essentially been eliminated by using a water seal system. Pericamditis occurred in 2.4% with good response to Indomethacin in 6 of 8 patients; 2 patients also required pericardial fluid aspiration. Pneumonia occurred in 0.9%, wound infection in 2.6%, resulting in bar infection in 3 of 7 patients. Long-term antibiotics were successful in curing the infection in one patient, whereas the other 2 required bar removal at 12 and 18 months, respectively. Bar displacement occurred in 8.8% of patients. However, the introduction of stabilizers decreased the incidence from 15.7 before the use stabilizers to 5.4% thereafter. Wiring the bar and stabilizer has decreased the incidence even further. Long-term outcome after bar removal showed an excellent result in 71%, good result in 21%, and recurrence in 8%. It is concluded that the minimally invasive technique has a low complication rate with excellent results.—Thomas A. Angerpointner Minimally Invasive Repair of Pectus Excavatum—The Nuss Procedure. A European Multicentre Study. S. Hosie, T. Sitkiewicz, C. Petersen, et al. Eur J Pediatr Surg 12:236-238, (August), 2002 Since the first description in 1998, the minimally invasive repair of pectus excavatum has gained increasing acceptance. The aim of this survey was to review the experiences of 8 European centers with the Nuss procedure. One hundred seventy-two patients with a mean age of 15.1 (⫾ 4.6) years were treated and evaluated. Thirty-six percent of the patients were symptomatic, whereas 45.3% had an assymetric chest configuration and 74.3% had a CT index above 3.25. Mean duration of the procedure was 76 minutes. Major complications, including bar or stabilizer dislocation, pneumonia, local infection, pleural and pericardial effusion and liver injury occurred in 11.1% of the patients. Minor complications, such as self-resolving pneumothorax, atelesasis, and subcutaneous emphysema were reported in another 8.1%. Early cosmetic results were excellent or good in 81.5%. Although the surgical procedure is simple, blood sparing, and short, consideration of some important details, proper patient selection, and knowledge of its limitations is of vital importance. Long-term results are still lacking.— Thomas A. Angerpointner The Use of Axiallary Skin Crease Incision for Thoracoptomian in Neonates and Children. A. Kalman and T. Verebely. Eur J Pediatr Surg 12:226-229, (August), 2002 Because of complications of the “standard” posterolateral thoracotomy, ie, winged scapula, acoliosis, different muscle-sparing approaches have been devised. In 1998, Bianchi et al. published their work on axillary skin crease incision for neonates, primarily for the repair of esophageal atresia. The aim of this study was to evaluate the usefulness of axillary skin crease incision compared with the traditional posterolateral approach. Twenty-six cases of axillary skin crease incision were reviewed. Axillary skin crease incision was used both in neonates and children (up to 15 years) in the treatment of mediastinal and pulmonary lessions. Seventeen operations were performed in neonates (8 esophageal atresia, 8 patent ductus arteriosus, one congenital cystic adenomatoid malformation) and 9 operations in children (3 neuroblastoma, one teratoma, 5 pulmonary operations). The approach provided unrestricted access through the axillary skin crease incision. When compared with posterolateral approach, there were no differ-

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ences in duration of the procedure, duration of postoperative ventilation, or other parameters. It is thus concluded that axillary skin crease incision should become standard for thoracotomies in neonates and children.—Thomas A. Angerpointner

ALIMENTARY TRACT Use of the Robot System DaVinci for Laparoscopic Repair of Gastroesophageal Reflux in Children. K. Heller, C. Gutt, B. Schaeff, et al. Eur J Pediatr Surg 12:239-242, (August), 2002. In adult patients, laparoscopic surgery, using a robot system (Da Vinci, Intuitive Surgical, Mountain View, CA), has been recently introduced into surgical practice. To investigate the feasibility of the system in pediatric surgery, laparoscopic fundoplications as well as cholecystectomies have been performed. In July 2000, the authors used the robot system for the first time in an 11-year-old girl with gastroesophageal reflux, and since that time on 7 other children. Altogether, 5 Thal and 3 Nissen procedures have been carried out. All operations were performed without complications and without conversion to open surgery. The average operating time was 146 min with a range of 103 to 180 minutes. Compared with conventional surgery, the 3-dimensional high-quality vision, the advanced instrument movements, and the ergonomic position of the surgeon seems to enhance surgical precision. It is, therefore, concluded that the use of the robot system is feasible and safe in pediatric surgery. The technique is limited because of the fact that instruments adapted to pediatric size are not yet available.—Thomas A. Angerpointner Long-Term Functional Results of Transhiatal Oesophagectomy and Colonic Interposition for Caustic Oesophageal Stricture. T.E. Bassiouny, S.A. Al-Ramadan and A. Al-Nady. Eur J Pediatr Surg 12:243-247, (August), 2002. Various surgical procedures have been advocated for the replacement of the scarred esophagus in children. The authors report on their experience with esophago-coloplasty. Over a 10-year period, 100 children (62 boys, 38 girls) with intractable caustic stricture of the esophagus underwent transhiatal esophagectomy and left colonic interposition. Their age at time of surgery ranged from 14 months to 8 years (mean, 3.4 years). The patients were followed up for a period from 5 to 15 years postoperatively. There were 3 deaths from respiratory failure. Stricture of the cervical esophagocolic anastomosis occurred in 6 patients and needed repeated dilatations (2 patients) and surgical revision (4 patients). Mild redundancy of the colonic substitute in the chest was noted in 5 cases, but there was no dysphagia necessitating revision of the colonic transplant. Peptic ulcer or symptomatic gastrocolic reflux was not seen. All patients are able to swallow and eat a normal diet. They gain weight and enjoy a normal life pattern. It is concluded that isoperistaltic left colon, based on both the ascending and descending branches of the left colonic vessels with simultaneous esophagectomy utilizing the transhiatal approach, is the best substitute for a scarred esophagus in children with satisfactory long-term results.—Thomas A. Angerpointner Tube Sigmoidostomy: A Modification of the Antegrade Colonic Evacuation. E.A. Kelly and B. Bowkett. Aust N Z J Surg 72: 397-399, (June), 2002. This article reports on 2 children with spina bifida and fecal incontinence in whom the appendix was not available for a Malone appendocecostomy. The authors considered a tubularized cecal valve but decided against this option because of the potential time delay between enema and evacuation. Rather, the same tubularization technique was applied to the sigmoid colon, constructing a tube sigmoidostomy around a 12F Foley catheter. With a clinical review period of between