Laparoscopy and thoracostomy in children

A variety of biologic products derived from bacteria, inflammatory cells, and active degraded proteins have been identified as having chemotactic activity essential for polymorphonuclear leukocyte (PMN) recruitment to the site of inflammation. Little is known, however, concerning factors responsible for regulating the intensity and duration of PMN recruitment. Evidence is growing that proteinase inhibitors modify the migrating ability of PMNs, although the physiologic implications of this have eluded clarification. In an attempt to hypothesize a role of alpha 1-proteinase inhibitor (alpha 1-Pi) in PMN recruitment to inflammatory sites, we examined the effects of alpha 1-Pi in different physiologic concentrations on PMN migration with a microchemotaxis chamber technique. Alpha 1-proteinase inhibitor had both stimulatory and inhibitory effects on cell migration, depending on its concentration. The inhibitor was active in inducing both directed locomotion (chemotaxis) and nondirected locomotion (chemokinesis) in concentrations of 0.02, 0.2, and 2 mg/ml, with maximum potency in both cases at 0.2 mg/ml (corresponding to the normal alveolar surface fluid level in the lung). Alpha 1-proteinase inhibitor impaired chemotactic responsiveness to known chemoattractants at 2 and 10 mg/ml (corresponding to normal and inflammatory blood levels, respectively) in order of potency. These results suggest that alpha 1-Pi may play a role in regulating inflammatory processes, especially in the lung, through its stimulatory and inhibitory effects, depending on its concentration.     

Laparoscopy for Crohn's disease in children

Traditionally, the diagnosis of Crohn's disease is established by colonoileoscopy and radiology. With these techniques the main area of interest, the distal ileum, is not easily reached. Also, the outer aspect of the bowel is ignored and there is no appreciation of the involvement of other intra-abdominal organs. Laparoscopy provides additional information. This may establish a more precise diagnosis, better standardization in comparative studies, and more specific therapy.     

US-guided hydrostatic reduction of intussusception in children

Over a period of 3 3/4 years, hydrostatic reduction of ileocolic intussusception was performed under sonographic guidance in 47 cases (a total of 41 consecutive patients). The enema consisted of a mixture of isotonic electrolyte solution and water-soluble contrast medium (9:1 ratio) and was given at a hydrostatic pressure of 80-100 cm water. Reduction was successful in 83% of cases (n = 39). Even initially remaining ileo-ileal intussusception could finally be reduced in two cases. No complications were observed. Since, in comparison with other conservative methods of reduction, the success rate was not substantially worse (versus that of pneumatic reduction) or was even higher (versus that of barium enema reduction), the method described can be recommended for wider use because of the substantial reduction in radiation exposure.     

Chronic intussusception in children: report of one case

Chronic intussusception is defined as intussusception lasting for 14 days or more. Because the clinical manifestation is different from that of acute intussusception, the diagnosis is usually delayed or missed. Ultrasonography is of diagnostic value. We present a 8-year-old boy who had the complaints of marked body weight loss and intermittent abdominal pain for one month. Hydrostatic reduction failed in this case. Laparotomy revealed an ileo-colic intussusception, the leading point of which was a colonic polyp. We would like to emphasize that chronic intussusception frequently appears a nonacute abdominal condition, usually intermittent abdominal pain, and sometimes marked body weight loss and an abdominal mass. Surgical intervention is usually needed in older children because a high incidence of underlying lesions in them.     

Patterns of recurrence of intussusception in children: a 17-year review

PURPOSE: Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. MATERIALS AND METHODS: Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. RESULTS: Above features (1)-(6) were the same in those managed with barium enema (1979-1985) and those managed with air enema (1985-1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. CONCLUSIONS: Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP.     

Laparoscopy in AIDS

Surgical problems in the patient with HIV and AIDS are becoming more commonplace as the incidence of HIV seropositivity increases and patients with AIDS are living longer. Laparoscopic surgery is being applied more frequently in the diagnosis and therapy of these patients' problems as more surgeons become familiar with the techniques. Although no prospectively randomized trials exist, the benefits of the laparoscopic approach clearly have had an impact on the morbidity associated with surgery. The decreased perioperative immune depression may benefit these patients, and risks to the operative teams probably are lessened if basic tenets of laparoscopic surgery are observed.     

Laparoscopy in gynaecological cancer

The use of laparoscopy in the management of gynaecological malignancies has significantly increased over the last 5 years. Patients with cervical, vaginal, endometrial and ovarian cancer can be managed laparoscopically either for staging or for treating. The feasibility of procedures through the laparoscope (such as hysterectomies, bilateral oophorectomies, pelvic and para aortic lymphadenectomies, omentectomies, colostomies, bowel resections, oophoropexies, radical hysterectomies and ovarian cancer debulking) has been demonstrated by skilled gynaecologists. Many of these procedures have been heralded as avant garde 'surgical standards' without appropriate evaluation of efficacy, effectiveness and efficiency. Larger series of patients have now replaced case reports to try to answer the numerous unanswered questions regarding the value of these procedures. Several prospective trials were begun to compare laparotomy and laparoscopy. If the results of these trials confirm the hope, laparoscopic management of gynaecological malignancies will leave the limited club of specialists to become a widely used technique. But the patients will benefit from laparoscopic procedures only when in the hands of well-trained surgeons.     

Chronic intussusception in childhood

A rare case of chronic intussusception is reported. Radiological investigation including ultrasound, CT and barium enema provided the correct diagnosis. Ultrasound revealed a solid mass near the transverse colon in the right lower abdomen. CT demonstrated the real nature of the solid mass as being the classical 'coiled spring' of intussusception. The barium enema was unsuccessful as an attempt at hydrostatic reduction, but confirmed the diagnosis by a 'crescent-shaped' filling defect in the ascending colon. The patient was discharged after an uneventful surgery and recovery. No organic lesion that precipitated the chronic intussusception was discovered at operation. Radiological findings, the typical clinical picture and adequate treatment are discussed.     

Laparoscopy for the undescended testis

The authors show their experience in the use of the laparoscopic approach in 18 cases of unilateral exploratory anorchia. They highlight the advantages that this method offers in efficiency, speed, security and minimal aggression compared with conventional exploration of the inguinal channel in the search of the undetectable testis. In the 18 cases studied through the insertion of 5 mm lense in the umbilical area, it was established that a testicular hypoplasia was present in 8 cases. In another 5 cases testicular agenesia was diagnosed, and in the remaining 5, intraabdominal testis were found. In four of these testicles, a laparoscopic approach helped in their correct placement and also in the removal of the fifth in a patient with recurrent leukemia.     

Laparoscopy in the management of the impalpable undescended testis

BACKGROUND: This study evaluates the role of laparoscopy for managing the intra-abdominal testis. METHODS: Over 30 months, 48 children (six with previous groin explorations) underwent laparoscopy for a unilateral impalpable undescended testis. The patients' age ranged from 1 to 9 years. RESULTS: Eleven children required insertion of 'working ports' for mobilization of obscuring colon before the diagnosis could be established. Twenty-eight children had an absent testis. In nine, vas and vessels entered the internal ring. In 19, vas and vessels ended blindly above the internal ring. Twenty children had an intra-abdominal testis. Ten underwent a laparoscopic single-stage orchidopexy (eight without and two with ligation of vessels); at a minimum follow-up of 2 years, one testis in this group had atrophied, three were located in the lower half of the scrotum and six in the upper half. The remaining ten children underwent a laparoscopic two-stage Fowler-Stephens operation. At a minimum follow-up of 6 months, eight of these testes were palpable in the lower half and two in the upper half of the scrotum. CONCLUSION In the majority of cases, laparoscopy obviates the need for groin exploration. Technically a first-stage Fowler-Stephens procedure can be performed easily and effectively via the laparoscope. However, the second-stage Fowler-Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide sufficient length to the testicular attachment.     

Laparoscopy in high-risk cardiac patients

Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.     

Laparoscopy in perforated gastroduodenal ulcers

The authors have performed operations on 32 patients with perforated ulcers of the duodenum and 7 patients with perforated ulcers of the stomach. The diameter of the perforations was 2-8 mm. In 10 of the 39 patients the perforation defects could not be sutured by the laparoscopic method. The authors consider that of great significance for the decision to make laparoscopic operations was the diagnosis of peritonitis, size and localization of the perforation, the surgeon's experience with endoscopic operating. The technique of laparoscopic suturing the perforations is described. Special attention is paid to the special disposition of the surgeon and his assistant at the operating table.     

Laparoscopy in abdominal injuries]

The desire to deliver protein and peptide biopharmaceuticals conveniently and effectively has led to intense investigation of site-specific drug-delivery systems. Despite challenges, progress towards the convenient noninvasive delivery of proteins and peptides has been achieved through specific routes of administration. In addition, the delivery of proteins and peptides to specific sites of action has been utilized to lower the total delivered dose, to gain access to specific organs or body compartments and to concentrate a therapeutic dose at a specific site of pharmacological action.     

Perinatal intussusception in premature infants

Intussusception is common in infants aged 5 to 18 months, but there have been only 12 reports of its occurrence among premature infants. Nine of these previously reported cases with adequate data and one new case are reviewed. Many of the infants were believed to have necrotizing enterocolitis, leading to an average 12-day interval between the onset of signs and the operation. Bilious emesis or nasogastric contents, bloody stool, and intestinal dilation without pneumatosis intestinalis were common. A contrast enema showed the intussusception in only 1 of 7 cases. Most cases were diagnosed in the operating room and underwent successful primary anastomosis, with no recurrences. A pathological lead point was identified in 2 of the 10 cases. The overall mortality rate was 23%; the one death since 1970 was secondary to attempted hydrostatic reduction. These cases may represent what, in the absence of premature delivery, would have been the intrauterine development of intussusception likely leading to small bowel atresia.     

Cecal intussusception in calves]

Among the patients admitted to the II. Medical Animal Clinic of the University of Munich from 1986 through 1994, there were 51 calves at an age of up to three months with intussusceptions in the caecal region. The following forms were observed: caecocaecal (n = 12), caecocolic (n = 22), ileocaecocolic (n = 6), ileocaecal (n = 8), and jejunoileocolic (n = 3). In 40 cases, the intussusception occurred in the course of diarrheal disease. The most important signs were scant faeces, that often contained blood and/or mucus, and the finding of a hard viscus upon abdominal palpation. Colic was observed in 27% of patients. In 18 cases, surgical intervention was not attempted because of the advanced stage of the disease or severe accompanying disease. From the remaining 33 calves, eight were cured. The others were either destroyed or died because of extensive peritonitis or other diseases. This report is to draw attention to the fact that (caecal) intussusception should be considered in diarrheal calves when faecal output decreases suddenly, and the general state deteriorates.     

Contribution of imaging in intestinal intussusception in the adult. Apropos of a case of ileocolic intussusception secondary to cecal lipoma

On the basis of a case of ileocolonic intussusception in a 35-year-old patient secondary to an obstructive lipoma of the caecum, the authors review the literature and discuss the clinical and radiological aspects of this disease. The diagnosis was established by CT scan and barium enema before surgery. Adult intussusception is a rare disease, which does not have any specific clinical features. Radiological imaging is the only complementary investigation which can suggest the diagnosis.