The prevention and treatment of parenteral nutrition-associated jaundice in infants and children.
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Bacterial Translocation↗
Biomedical subjects
K E Georgeson
Publications and source records attributed to K E Georgeson.
Surgical options for short bowel syndrome.
Most children with short bowel syndrome experience spontaneous small bowel adaptation over time. This allows the majority to be weaned from parenteral nutrition. There are, however, some children who cannot be weaned and are potential candidates for techniques to promote intestinal adaptation and intestinal lengthening. Here, surgical therapeutic options are described, literature reviewed, and reported results evaluated. Surgical procedures for children with short bowel syndrome have high complication and failure rates, but in most cases are a less invasive option than intestinal transplantation.
Child↗
Gut expression and regulation of FAT/CD36: possible role in fatty acid transport in rat enterocytes.
Fatty acid translocase (FAT)/CD36 is one of several putative plasma membrane long-chain fatty acid (LCFA) transport proteins; however, its role in intestinal absorption of LCFA is unknown. We hypothesized that FAT/CD36 would be differentially expressed along the longitudinal axis of the gut and during intestinal development, suggesting specificity of function. We found that intestinal mucosal FAT/CD36 mRNA levels varied by anatomic location along the longitudinal gut axis: stomach 45 +/- 7, duodenum 173 +/- 29, jejunum 238 +/- 17, ileum 117 +/- 14, and colon 9 +/- 1% (means +/- SE with 18S mRNA as control). FAT/CD36 protein levels were also higher in proximal compared with distal intestinal mucosa. Mucosal FAT/CD36 mRNA was also regulated during intestinal maturation, with a fourfold increase from neonatal to adult animals. In addition, FAT/CD36 mRNA levels and enterocyte LCFA uptake were rapidly downregulated by intraduodenal oleate infusion. These findings suggest that FAT/CD36 plays a role in the uptake of LCFA by small intestinal enterocytes. This may have important implications in understanding fatty acid absorption in human physiological and pathophysiological conditions.
Animals↗
A new technique for laparoscopic exploration to find contralateral patent processus vaginalis.
BACKGROUND: Contralateral inguinal exploration in an infant with a symptomatic unilateral hernia is controversial. A patent processus vaginalis (PPV) may be found in up to 60% of term infants, and even in a greater number of preterm infants. However, only 10% to 30% of children will subsequently develop a contralateral hernia when only the symptomatic side is repaired. Standard contralateral laparoscopic inguinal exploration (CLIE) usually is performed through the ipsilateral groin with an angled scope or through the umbilicus with a 0 degrees scope. A significant number of children have a peritoneal veil shrouding the internal ring. To enhance the accuracy of contralateral groin exploration, we have used a laparoscopic technique of directly visualizing the internal ring through a lateral abdominal approach. METHODS: From January 1993 through June 1997, we performed 141 CLIE on infants younger than 1 year of age with symptomatic unilateral inguinal hernia. After routine dissection on the symptomatic side, the sac was used to insufflate the abdominal cavity. A needle catheter was inserted on the contralateral abdominal wall and used to introduce a 1.2-mm scope. If a PPV was identified, the potential hernia was repaired using standard techniques. RESULTS: Of the 141 CLIEs performed on patients younger than 1 year of age, 39 (27.6%) were positive. There were no false-positives. In all, 42 CLIEs (29.7%) were performed on infants born at less than 36 weeks gestation, and 14 of these infants (33.3%) had a positive exploration. The patients were followed for 3 to 57 months. No complications resulted from the technique. One patient had a recurrence on the repaired side. No patients who had a negative CLIE subsequently developed a contralateral hernia. CONCLUSIONS: The lateral abdominal approach for laparoscopic evaluation of the contralateral groin is safe and accurate, requiring no additional incisions. Longer follow-up is necessary to determine the true false-negative rate.
Female↗
Advances in minimally invasive surgery in children.
Minimal access pediatric surgery has developed more slowly than its adult counterpart for several reasons. Surgical pain and perioperative stress associated with open procedures have been underappreciated in children. Appropriately sized instrumentation was slow to develop because the focus of the marketplace was the adult. The advanced techniques required for pediatric laparoscopic procedures are associated with a relatively long learning curve. Reports documenting the safety, efficacy, and cost effectiveness of pediatric endosurgery are fueling a rapid evolution in instrumentation and minimal access procedures for children. This evolution will eventually influence most pediatric surgical procedures, changing the paradigm of the practice of pediatric surgery. It is the pediatric patient who has the most to gain from these alterations in their surgical care with less pain, decreased hospital days, and earlier return to regular activities.
Adult↗
Laparoscopically assisted anorectal pull-through for high imperforate anus--a new technique.
BACKGROUND/PURPOSE: This report describes a new technique of laparoscopically assisted anorectal pull-through (LAARP) for repair of high imperforate anus. The procedure utilizes minimal perineal dissection, preservation of the distal rectum, and accurate placement of the rectum within the levator ani and external anal sphincter muscle complex. METHODS: Sharp dissection and cautery was used laparoscopically to expose the rectal pouch down to the urethral or vaginal fistula, which was clipped distally and divided. The pelvic floor musculature was then assessed and the levator sling identified. Externally, electrostimulation was used to define the center of the anal dimple. An 8-mm skin incision was made, centered at the strongest cephalad contraction. Using a hemostat, minimal blunt dissection on the perineum was guided by transillumination from the laparoscopic light source. A trocar, consisting of a radially expandable sheath over a Varess needle, was passed through this defined plane in the external sphincter muscle complex and advanced into the pelvis between the 2 bellies of the pubococcygeus muscle, guided by laparoscopic visualization. This perineal trocar therefore formed a passage through the center of the striated muscle complex and levators. The rectal fistula, which had been dissected out laparoscopically, was grasped using the perineal trocar and exteriorized to the perineum. Anorectal anastomosis was performed with absorbable interrupted suture. RESULTS: Seven patients were treated with initial colostomy in the newborn period followed by delayed LAARP 2 to 12 months later. In 4 newborn infants, the LAARP was performed as a primary procedure without prior colostomy. Laparoscopic mobilization has been possible on all cases attempted. All of the patients have a brisk and symmetric anal contraction with perineal electrostimulation. CONCLUSIONS: Lack of long-term follow-up precludes accurate assessment of the potential for fecal continence. However, short-term experience has been that this new method of pull-through for imperforate anus offers many advantages, including excellent visualization of the rectal fistula and surrounding structures, accurate placement of the bowel through the anatomic midline and levator sling, and minimally invasive abdominal and perineal wounds.
Anus, Imperforate↗
Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard.
OBJECTIVE: To describe the surgical technique and early clinical results after a one-stage laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease. SUMMARY BACKGROUND DATA: Recent trends in surgery for Hirschsprung's disease have been toward earlier repair and fewer surgical stages. A one-stage pull-through for Hirschsprung's disease avoids the additional anesthesia, surgery, and complications of a colostomy. A laparoscopic-assisted approach diminishes surgical trauma to the peritoneal cavity. METHODS: The technique uses four small abdominal ports. The transition zone is initially identified by seromuscular biopsies obtained laparoscopically. A colon pedicle preserving the marginal artery is fashioned endoscopically. The rectal mobilization is performed transanally using an endorectal sleeve technique. The anastomosis is performed transanally 1 cm above the dentate line. This report discusses the outcome of primary laparoscopic pull-through in 80 patients performed at six pediatric surgery centers over the past 5 years. RESULTS: The age at surgery ranged from 3 days to 96 months. The average length of the surgical procedure was 2.5 hours. Almost all of the patients passed stool and flatus within 24 hours of surgery. The average time for discharge after surgery was 3.7 days. All 80 patients are currently alive and well. Most of the children are too young to evaluate for fecal continence, but 18 of the older children have been reported to be continent. CONCLUSION: Laparoscopic-assisted colon pull-through appears to reduce perioperative complications and postoperative recovery time dramatically. The technique is quickly learned and has been performed in multiple centers with consistently good results.
Child↗
Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children.
BACKGROUND: The use of centrally positioned venous catheters plays an indispensable role in the care of infants and children. METHODS: Since 1992 the authors have seen nine patients who experienced fragmentation and migration of catheter fragments into the central circulation. The patients ranged in age from 6 days to 15 years. RESULTS: Sites of migration included pulmonary artery (five patients), superior vena cava (two patients), hepatic vein and innominate vein (one patient). The elapsed time from recognition of retained catheter fragments until retrieval ranged from a few hours to 6 weeks. CONCLUSION: All retained fragments were successfully removed during cardiac catheterization without complications.
Adolescent↗
Laparoscopic gastric antroplasty in children with delayed gastric emptying and gastroesophageal reflux.
BACKGROUND/PURPOSE: A significant number of children (50%) with gastroesophageal reflux (GER) have delayed gastric emptying (DGE). Although controversial, many pediatric surgeons use a gastric outlet procedure in conjunction with fundoplication for gastroesophageal reflux in these patients. This paper describes the technique and clinical outcome of 61 patients undergoing a laparoscopic gastric antroplasty at the time of the laparoscopic fundoplication. METHODS: The charts of 61 patients who underwent laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication between May 26, 1992 and October 17, 1996 were reviewed retrospectively. All patients had a documented DGE confirmed by a liquid isotope meal being retained in the stomach. After completion of the fundoplication, a laparoscopic antroplasty was performed by incising a 2 to 3.5-cm linear incision in the pylorus and distal gastric antrum. The seromuscular wall was divided to the level of the mucosa allowing the mucosa to bulge through the defect. The wound was closed transversely using interrupted 2-0 silk sutures. RESULTS: Four of the 61 patients underwent conversion to open antroplasty for technical reasons. The remaining 57 patients recovered uneventfully from the laparoscopic antroplasty with clinical resolution of both GER and DGE. Two of 57 patients had intermittent episodes of retching and were unable to tolerate large bolus feedings because of dumping. They were treated by dividing the feedings into two smaller portions. These symptoms cleared within 6 months. The remaining 55 patients have tolerated feedings well. Evaluation of the gastric emptying was performed randomly in selected patients with documented improvement of the emptying after antroplasty. An evisceration of omentum through the umbilical incision developed in one patient on the third postoperative day. CONCLUSIONS: Patients with delayed gastric emptying who need fundoplication can be treated with laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication. Laparoscopic antroplasty appears to be clinically efficacious in improving delayed gastric emptying.
Child↗
Fundoplication and gastrostomy.
Fundoplication and gastrostomy are among the most frequently performed procedures in infants and children. A laparoscopic approach with decreased morbidity has made fundoplication (with or without gastrostomy) more acceptable for patients who have significant gastroesophageal reflux disorders. Diagnostic evaluations to determine the presence of pathological gastroesophageal reflux have remained the same for patients being considered for open or laparoscopic procedures. Gastrostomy alone also is performed for patients who have swallowing difficulties or failure to thrive, after excluding the presence of gastroesophageal reflux. The authors review the indications and techniques of laparoscopic fundoplication and gastrostomy, as well as their experience with 390 patients.
Child↗
Laparoscopic pull-through procedure for Hirschsprung's disease.
Contemporary surgical management of Hirschsprung's disease (HD) has evolved toward resection and reconstruction earlier in life. The introduction and miniaturization of laparoscopic instrumentation currently permits the application of this approach to the treatment of HD in the neonate. The authors' experience with this technique demonstrates several potential advantages over the "classical" two-stage operation.
Female↗
The EXIT procedure facilitates delivery of an infant with a pretracheal teratoma.
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Adult↗
Laparoscopic fundoplication.
Symptomatic gastroesophageal reflux in children has been identified with increasing frequency over the last two decades. Agreement regarding the elements of a complete diagnostic work-up and the timing and specific surgical procedures for treating reflux has been difficult to achieve. Laparoscopic fundoplication is a routine procedure in some pediatric surgery centers. This surgical technique has the potential to reduce the pain and morbidity associated with open fundoplication. The outcomes after laparoscopic fundoplication have been equivalent to open fundoplication and are associated with faster recovery. Consensus regarding when to perform a partial fundoplication as compared to a complete fundoplication in addition to the appropriateness of gastric outlet procedures has not been achieved.
Child↗
Primary laparoscopic endorectal pull-through for Hirschsprung's disease in infants and children.
Colon pull-through for Hirschsprung's disease has classically been performed in multiple stages. Open primary pull-through procedures offer the advantages of shorter overall hospital stay, decreased morbidity, and earlier intestinal continuity, and colostomy is avoided. This article describes the techniques used and results obtained in 24 consecutive patients who had a laparoscopic primary endorectal pull-through for Hirschsprung's disease. The patients ranged in age from a few days to 6 years. Operative times ranged from 1-(1/2) hours to 3-(1/2) hours. Perioperative complications were relatively minor. None of the patients had clinical enterocolitis after primary laparoscopic pull-through, and there were no anastomotic strictures. Average postoperative length of stay was 3-(1/2) days. Primary laparoscopic endorectal pull-through is a safe and effective alternative to open primary or multistage pull-through procedures.
Biopsy↗
Laparoscopic fundoplication and gastrostomy.
Fundoplication and gastrostomy are among the more common operative procedures performed in infants and children. This article reviews the techniques, results, and complications of the surgical treatment of gastroesophageal reflux in 389 consecutive pediatric patients over the last 5 years. Chronic unremitting vomiting, failure to thrive, and an array of pulmonary symptoms were the leading indications for fundoplication in these children. Children who eat by mouth were primarily treated by a Toupet fundoplication, whereas gastrostomy-fed children generally received a Nissen fundoplication. The time to perform fundoplication and gastrostomy in our patients averaged about 3 hours for the first 10 patients but required a little over 1 hour for the last 50 patients. Most patients were discharged by the second or third postoperative day. Recurrent symptoms have developed in about 5% of our patients. Five of the 201 children who received a Toupet fundoplication (partial wrap) have been converted to a complete wrap fundoplication. Two of the patients having a Nissen fundoplication have required reoperation for their symptoms. The primary complications were seven cases of transient dysphagia, one case of esophageal perforation, and one case of gastric perforation. Laparoscopic fundoplication seems to achieve results equivalent to open fundoplication and is associated with considerably less postoperative pain and morbidity as well as a more rapid recovery.
Child↗
Hearing loss associated with neonatal ECMO: a clinical investigation.
To answer the question as to the prevalence of sensori-neural hearing loss (SNHL) among neonates receiving ECMO, a retrospective chart review was conducted on 198 infants having surgery between November 1987 and January 1995. One hundred fifty-seven (79.7%) survived. One hundred thirty infants met our criteria of having a pre-discharge auditory brainstem evoked response (ABR) test and at least one follow-up behavioral audiologic examination. Strict criteria were set for normal hearing on both the ABR and follow-up examinations. Only follow-up results are reported. At the time of the most recent follow-up examination, two children could not be adequately studied, 106 exhibited normal hearing, 21 (16%) exhibited either unilateral or bilateral conductive hearing loss and three (2.3%) exhibited unilateral or bilateral SNHL. Only one child is using amplification. With the largest sample size to date, we found a lower prevalence of SNHL after ECMO than has been previously noted in the literature. Although the prevalence of hearing loss is low, the post-ECMO group of infants must be considered at risk for hearing loss. The prevalence of hearing loss cannot be based solely on a pre-discharge ABR, i.e. ongoing follow-up testing is necessary.
Evoked Potentials, Auditory, Brain Stem↗
Gluteus maximus augmentation for the treatment of fecal incontinence.
Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.
Buttocks↗
The learning curve associated with laparoscopic antireflux surgery in infants and children.
Laparoscopic fundoplication is an effective method for treating gastroesophageal reflux in infants and children. Some surgeons prefer the traditional open technique and have concerns regarding complications associated with laparoscopic surgery as well as the time length of operation. This report addresses these concerns in a retrospective review of the first 160 consecutive pediatric patients who underwent laparoscopic fundoplication. "Learning Curves" as a function of surgical experience are presented highlighting some of the lessons learned while developing the laparoscopic fundoplication technique.
Adolescent↗