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Biomedical subjects

G Stringel

Publications and source records attributed to G Stringel.

At least 55 records · Page 3Linked to original sources

Lipoblastoma in infants and children.

Lipoblastoma and lipoblastomatosis are rare benign tumors of embryonal fat with a tendency to local invasion but not to metastasize. To date, there have been 60 cases described in the international literature. There has never been a report in a child older than 8 yr. The main clinical characteristics are the presentation, usually below 3 yr of age, the rapid growth of the mass and the peripheral location, mainly in the extremities. Although CT scan may show a fatty tumor, there is no single test to make the differential diagnosis (which includes benign lipoma, liposarcoma and myxoliposarcoma) and the treatment should be based on clinical findings. We have treated four patients with this condition. Two were intrathoracic, one was intraperitoneal, and one was a tumor of the upper arm. All presented as rapidly-growing tumors and were clinically assumed to be malignant. We recommend complete but conservative excision of the tumor; there are reported recurrences after inadequate excision. This is a benign tumor and radical cancer surgery should be avoided.

Abdominal Neoplasms↗

Fictitious pancreatitis in choledochal cyst.

The classical presentation of choledocal cyst has been regarded as a triad of abdominal pain, jaundice and a palpable abdominal mass; unusual presentations include rupture of the choledocal cyst with bile peritonitis, pancreatitis and bleeding esophageal varices. We are reporting 3 children presenting clinically as recurrent acute pancreatitis with elevated serum amylase and found to have type I choledocal cyst. Despite elevated serum amylase there was no evidence of pancreatic inflammation at laparotomy. High amylase concentration was found in fluid contained within the cyst. This was probably responsible for the elevated serum amylase and also the inflammatory reaction seen in the wall of the choledocal cyst. These cases support the hypothesis that pancreatic reflux into the bile ducts is the etiological factor in the development of choledocal cyst. Our 3 cases were treated by cyst excision and have remained asymptomatic. The presence of hyperamylasemia should not delay appropriate surgical management. The treatment of choice is cyst excision, since it will eliminate factors contributing to the development of cholangitis and hyperamylasemia.

Adolescent↗

Torsion of the wandering spleen: splenectomy or splenopexy.

Torsion of the wandering spleen is a rare condition usually unsuspected preoperatively. In previously reported cases in the past, attempts at splenopexy have failed and splenectomy has been regarded as the treatment of choice. We are presenting two children with splenic torsion. In one complete infarction of the spleen had occurred and so splenectomy could not be avoided. In the second, the spleen was viable and splenopexy was successfully performed. The clinical presentation, etiology, diagnostic procedures and management are discussed, and a surgical technique for splenopexy is described.

Child↗

Balloon embolization of a bleeding gastroduodenal artery in a 1-year-old child.

Severe stress can produce ulceration and uncontrollable hemorrhage in the pediatric age group. Modern angiographic techniques, using embolization of a Silastic balloon to occlude a visualized bleeding vessel, can successfully control hemorrhage and avoid surgical intervention and its resultant disordered gastric physiology. Recently this technique was used to control hemorrhage from the gastroduodenal artery in a 1-year-old child with severe respiratory sepsis. This is the youngest reported child in whom the technique has been used to control bleeding from this vessel.

Aneurysm↗

Treatment of choledochal cyst by excision.

Since 1969 excision of choledochal cyst and establishment of bile drainage by Roux-en-Y hepaticojejunostomy has been performed in 7 children whose ages ranged from 10 mo to 11 yr. In 3 children, the cyst had been treated 5 yr, 4 wk, and 3 wk previously by cystduodenostomy, cystjejunostomy, and cholecystduodenostomy, respectively; further surgery was indicated for biliary obstruction and severe cholangitis. The other four children were not acutely ill. All cysts were located distal to the confluence of the right and left hepatic ducts. The volume of the smallest cyst was 25 ml and the largest 500 ml. In all children a small remnant of distal cyst was not excised to avoid injury to the duodenum and pancreas. In four children a remnant of proximal cyst was left attached to the hepatic duct to allow a large biliary intestinal anastomosis and minimize the possibility of stricture. No serious intraoperative problems were encountered. Prolonged drainage (2-3 wk) from Penrose drain sites in two children were the only postoperative complications. Liver function tests have remained normal in all and no episodes of cholangitis or jaundice have been noted during follow-up (median: 4.5 yr). This experience supports recent reports that indicate that cyst excision is associated with low mortality and morbidity. Cyst excision is preferred over traditional internal drainage procedures because it (A) eliminates a reservoir for bile stasis, (B) removes a mechanism which allows continuous reflux of pancreatic juice into the cyst, and (C) probably prevents the occurrence of bile duct carcinoma which has been noted in 3.0% of patients with choledochal cyst.

Adolescent↗

Pheochromocytoma in children--an update.

Eight cases of pheochromocytoma in children were managed between 1958 and 1978. Headache, visual blurring, sweating, and hypertension were the most common findings. One patient presented with a hypertensive crisis during appendectomy. Three other children had a family history of pheochromocytoma and Hippel-Landau disease, thyroid carcinoma, and renal stones. The diagnostic approach was based on a high suspicion of the disease from the clinical picture. The most reliable laboratory investigations were urinary VMA, metanephrine, and catecholamines. I.V.P. and angiography were successful in localizing the tumor. In 4 cases, CT scan localized the tumor, although a second tumor was not seen in 1 case. Preoperative control of hypertension was achieved with phenoxybenzamine, propanolol, apresoline and reserpine in seven cases. The main anesthetic drugs used were pentothal, methoxyflurane, nitrous oxide, Innovar, and pancuronium. Tumors were located in the right adrenal in four, the left adrenal in two, both adrenals in one, and bilateral para-aortic sites in one. In two cases, hypertensive episodes during manipulation of the tumor were controlled with phentolamine. Ligation of the venous drainage from a tumor was associated with a sudden sustained fall in systemic blood pressure in six cases. In two, blood pressure remained elevated until a second tumor was found and removed. Hypotension was then corrected by the rapid infusion of fluid and blood, and vasopressors were not used. There were no postoperative complications and all children remained normotensive during the follow-up. The tumors of seven of the patients were benign. One tumor showed a low grade malignancy.

Adolescent↗

Prognostic factors in omphalocele and gastroschisis.

Size of the abdominal wall defect, viscera exposed or herniated, birth weight, associated medical conditions and congenital anomalies, mode and complications of treatment, and the use of total parenteral alimentation was reviewed in 79 cases of omphalocele and 44 cases of gastroschisis treated in the past 10 yr. Sixty-seven percent of infants with omphalocele and 73% of those with gastroschisis survived. In omphalocele, the most important factors affecting mortality were the presence of other associated abnormalities and low birth weight. The size of the abdominal wall defect, the viscera herniated, and the mode of treatment did not appear to affect mortality. In gastroschisis, the size of the abdominal defect, birth weight, viscera exposed or herniated, and associated anomalies were not significant factors affecting mortality. Mortality was usually secondary to intestinal or wound complications. Statistical analysis could not prove that primary repair resulted in greater survival than the use of a silon pouch, but analysis of complications clearly indicates that the former method is preferable and that silon pouch should be reserved for cases in which primary repair is not possible.

Abdominal Muscles↗

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the application of video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population. PATIENTS AND METHODS: Between 1995 and 1997, four patients with recurrent spontaneous pneumothorax were treated. Ages varied from 14 to 17 years. There were three males and one female. Two patients had spontaneous pneumothorax twice, and the other two had it three times. Three patients had primary spontaneous pneumothorax, and the fourth one had spontaneous pneumothorax secondary to cystic fibrosis. Computerized tomography of the chest demonstrated blebs in two patients, and in the other two it was suggestive of apical blebs but not definitive. All patients had failed treatment by tube thoracostomy. Video-assisted thoracoscopy demonstrated blebs in all patients. Removal was easily accomplished with an endoscopic automatic stapling device. The procedure was completed with mechanical pleurodesis, multiple intercostal blocks and intrapleural bupivacaine for control of pain. RESULTS: All patients had a quick and uneventful recovery. Follow-up ranged from one to three years. There were no complications or subsequent recurrences of the pneumothorax. CONCLUSIONS: Video-assisted thoracoscopy is a safe and effective technique in recurrent spontaneous pneumothorax. It allows for accurate identification and removal of the blebs, with quick recovery, minimal discomfort and good cosmetic results.

Adolescent↗

Laparoscopy in the management of children with chronic recurrent abdominal pain.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain. PATIENTS AND METHODS: Thirteen children with chronic recurrent abdominal pain were subjected to diagnostic laparoscopy. Ages varied from 10 to 17 years. There were six males and seven females. Abdominal pain was present from 3 weeks to 12 months (mean, 2 months). Extensive laboratory and imaging studies did not contribute to the diagnosis. In all patients, the pain was disabling and severe enough to warrant repeated visits to the pediatrician, emergency room visits, or hospital admissions, as well as absence from school. RESULTS: All children recovered uneventfully. Laparoscopic findings that identified the cause of abdominal pain were obtained in 12 of 13 patients. Laparoscopic appendectomy was done in all patients. There were no operative complications. One child presented three months later with incomplete small bowel obstruction, which resolved with conservative management. There were no other postoperative complications. Follow-up varied from six months to three years. Abdominal pain resolved in ten patients. One patient presented eight months later with biliary dyskinesia. She improved following laparoscopic cholecystectomy and later on sphincterotomy, but her pain has not yet completely resolved. One patient presented six months later with abdominal pain secondary to intestinal adhesions. Her pain completely resolved after laparoscopic lysis of adhesions. A third patient who developed lower abdominal pain six months after laparoscopy improved with conservative management and antibiotics for pelvic inflammatory disease. CONCLUSIONS: Diagnostic laparoscopy is a valuable procedure in the management of children with chronic recurrent abdominal pain. In the present study, laparoscopic examination revealed the cause of abdominal pain in most patients, and this pain resolved in most cases. Based on our experience, we recommend diagnostic laparoscopy early in the course of debilitating chronic recurrent abdominal pain in children. Appendectomy should be done when no other significant cause of abdominal pain has been identified, even if the appendix looks normal.

Abdominal Pain↗

Laparoscopic Nissen fundoplication in children: a single surgeon's experience.

BACKGROUND AND OBJECTIVES: Adult laparoscopic Nissen fundoplication has been steadily growing since its introduction to the United States in the 1990s. Its advantage over the traditional open approach is manifold. Application of laparoscopic fundoplication to children is slowly but surely following this trend. This study evaluates our initial experience with pediatric laparoscopic Nissen fundoplications. PATIENTS AND METHODS: We reviewed the records of 25 consecutive laparoscopic Nissen fundoplications performed by a single surgeon (GS) at our institution in the past three years. The patient ages ranged from 7 months to 18 years (mean, 7 years). All patients had documented gastroesophageal reflux disease. Complications from the reflux included vomiting in 15 patients, failure to thrive in nine, esophagitis in nine, and pulmonary symptoms in six. RESULTS: All Nissen fundoplications were performed laparoscopically without need for conversion to open technique. Blood loss was less than 50 cc in all cases. A tube gastrostomy was concurrently performed in 17. Mean operative time in all cases was 221 minutes. Average postoperative day on which feedings were begun was day 2, with an average resumption of regular feedings on postoperative day 3.5. Average date of discharge was postoperative day 6.8. Complications included difficulty controlling glucose in an insulin-dependent diabetic, and a lost needle, which added an additional hour to the operative time. There were eight admissions to the pediatric intensive care unit, all for observation secondary to their underlying medical problems. There was one postoperative death due to an underlying medical condition. CONCLUSIONS: Laparoscopic Nissen fundoplication is a safe and effective treatment option for children suffering from significant reflux. Time to regular feeding, analgesia requirements and hospital stay are decreased when compared to traditional procedures. Laparoscopic Nissen fundoplication may well become the procedure of choice for pediatric gastroesophageal reflux disease.

Adolescent↗

Laparoscopic splenectomy in pediatric patients with hematologic diseases.

OBJECTIVE: The aim of this study was to evaluate our experience with laparoscopic splenectomy in pediatric patients with hematologic diseases. METHODS: A retrospective chart review was performed to analyze the following: indication for splenectomy, pre- and peri-operative management, surgical technique, complications, duration of hospitalization, and outcome. RESULTS: Eleven patients underwent laparoscopic splenectomy for the following indications: recurrent thrombocytopenia (<10,000) in seven with chronic immune thrombocytopenic purpura; anemia in two with hereditary spherocytosis; and hypersplenism in one and recurrent splenic sequestration in another with homozygous hemoglobin S. The six girls and five boys had a median age of 7 years. The median operative time was 180 minutes, and the median hospitalization was 72 hours. Among the patients with immune thrombocytopenic purpura (median platelet count, 153,000), those patients (n=3) with platelet counts of <100,000 did not suffer any bleeding complications. The patient with hypersplenism and homozygous hemoglobin S required a small incision in the left lower quadrant to facilitate removal of a 558-gram spleen. This patient also underwent cholecystectomy for cholelithiasis. The operative time was 295 minutes, and he was hospitalized for 5 days because of atelectasis. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematological disorders.

Adolescent↗

Thoracoscopic ligation of the thoracic duct.

OBJECTIVE: When nonoperative treatment of chylothorax fails, thoracic duct ligation is usually performed through a thoracotomy. We describe two cases of persistent chylothorax, in a child and an adult, successfully treated with thoracoscopic ligation of the thoracic duct. METHODS: A 4-year-old girl developed a right chylothorax following a Fontan procedure. Aggressive nonoperative management failed to eliminate the persistent chyle loss. A 72-year-old insulin-dependent diabetic man was involved in a motor vehicle accident, in which he sustained multiple fractured ribs, a right hemopneumothorax, a right femoral shaft fracture, and a T-11 thoracic vertebral fracture. Subsequently, he developed a right chylothorax, which did not respond to nonoperative management. Both patients were successfully treated with thoracoscopic ligation of the thoracic duct. RESULTS: The child had significant decrease of chyle drainage following surgery. Increased drainage that appeared after the introduction of full feedings five days postoperatively was controlled with the somatostatin analog octreotide. The chest tube was removed two weeks after surgery. After two years' follow-up, she has had no recurrence of chylothorax. The adult had no chyle drainage following surgery. He was maintained on a medium-chain triglyceride diet postoperatively for two weeks. The chest tube was removed four days after surgery. After six months' follow-up, he has had no recurrence of chylothorax. CONCLUSIONS: Thoracoscopic ligation of the thoracic duct provides a safe and effective treatment of chylothorax and may avoid thoracotomy and its associated morbidity.

Aged↗

Idiopathic post-operative pulmonary hypertension in the newborn.

A case of severe pulmonary hypertension following the primary repair of an omphalocele in a term infant is reported. There were no pre-disposing factors known to contribute to the postoperative pulmonary hypertension (PPH). Therapy was successful first by using hyperventilation, and then subsequently with tolazoline. Upper gastrointestinal bleeding limited the use of tolazoline after the first fourty-eight hours. Complete recovery ensued. The occurrence of PPH and the current therapy of this unpredictable condition is discussed.

Carbon Dioxide↗

Laparoscopic appendectomy in children.

BACKGROUND AND OBJECTIVES: The advantages of laparoscopic appendectomy over open appendectomy have not yet been clearly demonstrated. The present study evaluated our early experience with laparoscopic appendectomy in children, in terms of its safety, effectiveness, technical difficulties, and economics. METHODS: We reviewed the records of 50 cases involving laparoscopic appendectomy performed at our affiliated institutions between September, 1994, and September, 1996. Patient age ranged from 6 to 18 years (mean, 14 years). Thirty-two patients had acute nonperforated appendicitis, six had perforated appendicitis, two had fibrosis of the appendix, and ten had a histologically normal appendix. RESULTS: In five patients the laparoscopic procedures were converted to open appendectomies because of technical difficulties. There were postoperative complications in four patients: one incomplete appendectomy which subsequently required an open appendectomy for completion, one pelvic abscess, one bowel obstruction, and one minor wound infection. CONCLUSIONS: Laparoscopic appendectomy is a safe and effective procedure. It takes longer operative time than open appendectomy. Length of hospitalization and incidence of postoperative complications are equivalent to those of open appendectomy. Economic benefits are difficult to assess at present. In sum, we believe that with better training, surgical techniques and equipment, laparoscopic appendectomy will eventually become the surgical procedure of choice in appendicitis.

Adolescent↗

Video-assisted thoracoscopy for the diagnosis of mediastinal masses in children.

BACKGROUND AND OBJECTIVES: Video-assisted thoracoscopy has been successfully used for several different thoracic procedures in adults. However, its use in children has been limited. The present study evaluated our experience with video-assisted thoracoscopy in the diagnosis of mediastinal masses in children. METHODS: Nine children (age range, 3 to 18 years) with undiagnosed mediastinal masses underwent video-assisted thoracoscopy. The operation was performed using general anesthesia, with the patient intubated with a single lumen endotracheal tube. RESULTS: In all cases adequate tissue for diagnosis was obtained. Three patients had tuberculosis, two had Hodgkin's disease, two had granuloma, one had metastatic Wilms' tumor, and one had thymic hyperplasia. There were no complications related to the operative procedure. CONCLUSIONS: Video-assisted thoracoscopy for the diagnosis of mediastinal masses in children is a safe procedure. It provides good visualization, access to the mediastinum and adequate tissue for diagnosis. Further, postoperative discomfort is tolerable and cosmetic results are excellent.

Adolescent↗

Polypoid lesions of the gallbladder in children.

Polypoid lesions of the gallbladder in children are rare. We report a case of a gallbladder polyp in a 14-year-old boy who presented with recurrent right upper quadrant abdominal pain. Ultrasound examination of the abdomen revealed a polypoid lesion of the gallbladder. His symptoms resolved after laparoscopic cholecystectomy. Histological examination of the gallbladder demonstrated a benign adenomatous polyp. Although the experience with polypoid lesions of the gallbladder in children is limited, we currently recommend cholecystectomy because these lesions are associated with acalculous cholecystitis, and because their long-term effects are unknown.

Adolescent↗

Video-assisted thoracoscopic surgery in the management of pediatric empyema.

BACKGROUND: Management of empyema in children has progressed from open thoracotomy to video-assisted thoracoscopic surgery (VATS). The purpose of the present study was to evaluate the efficacy and safety of VATS in children with multiloculated empyemas. METHODS: Nine children (mean age, 4 years; range, 21 months to 13 years) with empyema, in whom multiple loculations were found on computed tomography, were treated with VATS from January, 1994, to November, 1996. All patients underwent VATS under general anesthesia, with drainage of the empyemas, decortication, and placement of chest tubes under direct vision. RESULTS: In all nine patients, VATS was successful. Average operating time was 120 minutes. Blood loss was insignificant, except in one patient who needed an intraoperative blood transfusion. This child required extensive decortication, with blood oozing from raw areas. All patients recovered well, with no recurrences to date. An algorithm for the use of VATS in the treatment plan for children with empyema was established. CONCLUSION: VATS provides safe and effective treatment in the management of pediatric empyema. Moreover, it avoids lengthy hospitalization, prolonged intravenous antibiotic therapy, and unnecessary pain and stress secondary to placement of chest tubes without anesthesia.

Adolescent↗