Hemodynamic and catecholamine responses to a laparoscopic adrenalectomy for pheochromocytoma in a pediatric patient.
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Adrenal Gland Neoplasms↗
Biomedical subjects
G W Holcomb
Publications and source records attributed to G W Holcomb.
Differentiated thyroid cancer: determinants of disease progression in patients <21 years of age at diagnosis: a report from the Surgical Discipline Committee of the Children's Cancer Group.
OBJECTIVE: This study was done to define the extent of disease and evaluate the effect of staging and treatment variables on progression-free survival in patients with differentiated thyroid carcinoma who were less than 21 years of age at diagnosis. SUMMARY BACKGROUND DATA: Differentiated thyroid cancer in young patients is associated with early regional lymph node involvement and distant parenchymal metastases. Despite this, the overall long-term survival rate is greater than 90%, which suggests that biologic rather than treatment factors have a greater effect on outcome. METHODS: Variables analyzed for their impact on progression-free survival in a multi-institutional cohort of 329 patients included age, antecedent thyroid irradiation, extrathyroidal tumor extension, size, nodal involvement, distant metastases, technique of thyroid surgery and lymphatic dissection, initial treatment with 131Iodine, residual cervical disease, and histopathologic subtype. Surgical complications were correlated with the specific procedures completed on the thyroid gland or cervical lymphatics. RESULTS: The overall progression-free survival rate was 67% (95%, CI: 61%-73%) at 10 years with 2 disease-related deaths. Regional lymph node and distant metastases were present in 74% and 25% of patients, respectively. Progression-free survival was less in younger patients (p = 0.009) and those with residual cervical disease after thyroid surgery (p = 0.001). Permanent hypocalcemia was more frequent after total or subtotal thyroidectomy (p = 0.001) while wound complications increased after radical neck dissections (p < 0.00001). CONCLUSIONS: The progression-free survival rate was better after a complete resection and in older patients. Progression-free survival rate was the same after lobectomy or more extensive thyroid procedures, but comparison was confounded by the increased use of total or subtotal thyroidectomy in patients with advanced disease. The risk of permanent hypocalcemia increased when total or subtotal thyroidectomy was done. Thyroid lobectomy alone may be appropriate for patients with small localized lesions while total or subtotal thyroidectomy should be considered for more extensive tumors.
Adolescent↗
Laparoscopic esophagomyotomy as treatment for achalasia.
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Child↗
Laparoscopic cholecystectomy.
Cholelithiasis is being recognized more frequently in the pediatric population. Although hemolytic diseases have an identifiable etiology, the origin of gallstones in approximately 80% of pediatric patients remains unknown. Infants with cholelithiasis can be managed expectantly unless symptoms develop because many of these stones will resolve spontaneously. The 2- to 12-year age group is more likely to present with chronic cholecystitis and will require cholecystectomy at some point, since there is little chance of spontaneous resolution of these gallstones. Teenagers tend to present in a similar manner to adults and are managed much the same way. Although plain radiographs are more useful in children than in adults, abdominal ultrasonography remains the most useful tool to document cholelithiasis. Safe access to the abdominal cavity is the first step to successful laparoscopic cholecystectomy, and the arrangement of secondary ports varies with the age and size of the patient. Choledocholithiasis can be managed laparoscopically in experienced hands, and endoscopic retrograde cholangiopancreatography plays a diagnostic as well as therapeutic role for this problem. Laparoscopic cholecystectomy has become the standard of care for all children in whom cholecystectomy is required.
Adolescent↗
Laparoscopic cholecystectomy.
Historically, cholelithiasis in children was thought to develop secondary to hemolytic disease. Within the past 20 years, however, its incidence in children without hemolysis is being diagnosed more frequently. Laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children. Many of the principles for this technique in children are similar to those in the adult population. Because of the patient's smaller size and more pliable abdominal wall, however, several improvements in technique have been developed. In addition, special precautions are necessary in children because of other unique characteristics. At Children's Hospital, Vanderbilt University Medical Center, 80 infants and children have undergone laparoscopic cholecystectomy since June 1990 without intraoperative or postoperative complications. Modifications in the operative technique used in these patients are detailed.
Adult↗
Diagnostic laparoscopy for congenital inguinal hernia.
Repair of indirect inguinal hernias is the most common general surgical procedure in infants and children. The question of whether or not to explore the contralateral side, however, has been the source of much debate among pediatric surgeons. With the advent of laparoscopy and the development of miniature telescopes, diagnostic laparoscopy has been advocated to decide in which child the contralateral side should be explored and a patent processus vaginalis ligated. This article describes the historical perspective in which this technique developed, the technique itself, and a report of the author's experience.
Child↗
Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia.
OBJECTIVE: To devise a clinically relevant grading system for the sonographic evaluation of parapneumonic effusions, and to evaluate length of hospital stay as a function of treatment approach and sonographic grades. METHODS: Chest sonograms of 46 pediatric patients diagnosed with empyemas and admitted to two medical centers in the last 8 years were retrospectively evaluated using a grading system based on the degree of fibrinous organization within the parapneumonic effusions. Hospital charts were reviewed to determine the method of treatment and length of hospital stay. Patients were divided into two treatment groups: nonoperative (n = 26) (antibiotics alone, or combined with thoracentesis, or tube thoracostomy) and operative (n = 20) (open decortication, or video thoracoscopy and pleural debridement). Patients in the nonoperative group were further subdivided into two groups: those who received antibiotics alone (n = 11) and those who received antibiotics plus nonoperative drainage thoracentesis and/or tube thoracostomy (n = 15). Within each treatment group, patients were subdivided into two ultrasound grades: low (no evidence of organization) and high (evidence of organization such as fronds, septations, or loculations). Student's t test was performed to compare the lengths of hospital stay for each of the treatment groups and ultrasound grades. RESULTS: The length of hospitalization was no different for patients with low-grade ultrasounds in the nonoperative (9.8 days) and operative groups (8.0 days). In contrast, length of hospitalization was significantly shorter for patients with high-grade sonograms in the operative group (8.6 days), when compared with the nonoperative group (16.4 days). Length of hospitalization for patients in the nonoperative group with high-grade sonograms was significantly longer (16.4 days) than for those with low-grade ultrasounds (9.8 days). Furthermore, when the nonoperative patients were divided into an antibiotics alone group and a nonoperative drainage group, the patients with low-grade sonograms had no difference in the length of hospitalization (9.0 days vs. 10.4 days), whereas those patients with high-grade sonograms in the nonoperative drainage group had a significantly longer hospitalization (19.9 days) than the antibiotics alone (high-grade) group (11.4 days). CONCLUSIONS: Patients with a low-grade sonogram had similar length of hospitalization if treated with either nonoperative or operative measures. Patients with high-grade sonograms had significantly shorter length of hospitalization when treated with decortication. Our retrospective study suggests that patients with high-grade ultrasound studies treated nonoperatively do not benefit from pleural drainage procedures or chest tube placement. This study demonstrates the usefulness of early sonographic evaluation of parapneumonic effusions. A prospective study evaluating the usefulness of sonographic assessment of severity of disease in the treatment of children with parapneumonic effusions is warranted on the basis of our retrospective data.
Adolescent↗
The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia.
We retrospectively reviewed 30 patients with achalasia (18 males, 12 females) undergoing laparoscopic Heller myotomy without antireflux procedure to determine relief of dysphagia and prevalence of postoperative gastroesophageal reflux. Preoperative symptoms were obtained by history alone before 1996 and by standardized questionnaire after September 1996. Twenty-nine patients (97%) had dysphagia, 22 patients (73%) had regurgitation, 21 patients (70%) had weight loss, 7 patients (23%) had heartburn, and 4 patients (13%) had nocturnal aspiration. The first 3 patients were done thoracoscopically, with the subsequent 27 patients performed laparoscopically; 4 cases (13%; 1 thoracoscopic and 3 laparoscopic) were converted. The mean postoperative stay was 1.9 days (1-6 days). One patient underwent repeat laparoscopic myotomy for persistent dysphagia. Twenty-eight patients (93%) were available for follow-up. Patients were asked on a standardized questionnaire to grade their relief of dysphagia, regurgitation, and heartburn. Good to excellent relief of dysphagia was obtained in 25 patients (89%), whereas 3 patients (11%) continued to have significant dysphagia postoperatively. Twenty-four patients (86%) had little or no regurgitation. Four patients (14%) had frequent regurgitation. Twenty-four patients (89%) reported little or no heartburn. Three patients (11%) reported significant postoperative heartburn. Laparoscopic Heller esophagomyotomy without antireflux procedure provides excellent symptomatic relief of dysphagia in patients with achalasia. Early follow-up suggests that minimal occurrence of symptomatic postoperative reflux can be achieved without performing an antireflux procedure.
Adolescent↗
Laparoscopic surgical treatment of achalasia.
BACKGROUND: The authors have performed 11 myotomies in 10 patients (aged 12 to 77) with achalasia using minimally invasive techniques. METHODS: The initial 3 patients were treated via transthoracic approach; the subsequent 7 patients via transabdominal approach. The length of the myotomy was determined in conjunction with intraoperative endoscopy to facilitate dissection and demonstrate division of the lower esophageal sphincter. RESULTS: Only 1 patient required intravenous and intramuscular narcotics more than 24 hours postoperatively; 2 patients required no postoperative narcotics. The average hospital stay for those patients successfully treated endoscopically averaged 2.0 +/- 0.5 days (range 1.5 to 3). One patient was converted to open thoracotomy secondary to perforation of the mucosa. One patient required repeat laparoscopic myotomy at 3 months due to recurrent dysphagia. Follow-up conducted at clinic visits showed all patients to have benefitted with relief of dysphagia; 80% (8) reported excellent results, 10% (1) reported good results, and 10% (1) fair results. CONCLUSION: We converted from thoracic to laparoscopic myotomy because the abdominal approach simplified anesthetic and surgical management. We conclude that laparoscopic myotomy is a simple and effective treatment of achalasia.
Adolescent↗
Anesthetic management for laparoscopic cholecystectomy in children with decreased myocardial function: two case reports.
This report describes the anesthetic management of two children with myocardial dysfunction undergoing laparoscopic cholecystectomy.
Anesthesia, General↗
The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy.
Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.
Adolescent↗
Video-assisted thoracoscopic diskectomy and fusion.
Thoracoscopic diskectomy has been described in adults as an alternative to thoracotomy for access to the anterior spine for correction of scoliosis, but its use in children for correction of spinal deformities has not been reported. Eight patients have undergone video-assisted thoracoscopic diskectomy with fusion before posterior instrumentation. In five patients, the posterior fusion and instrumentation followed the thoracoscopic procedure under the same anesthesia; in three patients it was staged and performed 1 week later. The mean time required for the thoracoscopic procedure was 174 minutes. Intraoperative bleeding requiring transfusion developed in one patient. No other complications occurred. The authors conclude that the minimally invasive approach for access to the thoracic cavity for anterior diskectomy and fusion will be the preferred approach because of the potential for significant reduction in postoperative discomfort and complications such as atelectasis and pneumonia. Postoperative hospitalization may not be decreased, however, because the patient must still recover from the open posterior instrumentation and fusion operation.
Adolescent↗
Retroperitoneal pulmonary sequestration: imaging findings, histopathologic correlation, and relationship to cystic adenomatoid malformation.
OBJECTIVE: Retroperitoneal bronchopulmonary sequestrations are rare congenital lesions that have been increasingly reported as incidental findings in utero. We present our case material of congenital retroperitoneal sequestration, discuss the reported imaging and histopathologic characteristics of this entity, and provide an approach to subsequent clinical and surgical management. CONCLUSION: Our data suggest that the imaging findings in retroperitoneal sequestration are characteristic and that faulty mesenchymal induction of pulmonary tissue within the retroperitoneum renders internal development into cystic adenomatoid malformation the rule rather than the exception. In the typical case, surgical removal is nonemergent.
Bronchopulmonary Sequestration↗
Hyperthermia during repair of pectus excavatum.
We have observed an elevation of body temperature during surgical repair of pectus excavatum. To document this phenomenon and attempt to prevent it, we undertook a combination retrospective-prospective study. The retrospective arm included an analysis of the anesthetic records of patients undergoing repair of pectus excavatum during the past 5 years and included 22 boys and 3 girls. Body temperature increased in all 25 patients, from a starting temperature of 36.1 degrees C +/- 0.5 degree C to 38.0 degrees C +/- 0.6 degree C. The maximum temperature exceeded 38 degrees C in 12 patients and 39 degrees C in 3 patients. An additional retrospective review of the anesthetic records of 15 children undergoing another type of thoracic procedure (thoracotomy) for noninfectious problems revealed only a modest, statistically nonsignificant rise in temperature from a starting point of 35.9 degrees C +/- 0.7 degree C to a maximum of 36.3 degrees C +/- 1.2 degrees C. The maximum temperature was greater than 38 degrees C in one of these 15 patients. The prospective arm of the study included a standardized anesthetic technique in 10 patients. Neither a heated humidifier nor a warming blanket were used, and the ambient temperature of the room was maintained at 70 degrees F. Core body temperature increased from a starting temperature of 36.1 degrees C +/- 0.6 degree C to 36.8 degrees C +/- 0.8 degree C. A significant elevation of body temperature occurs in children during repair of pectus excavatum that may be avoided by eliminating the use of exogenous methods to prevent hypothermia (e.g., heated humidifier, warming blanket).
Adolescent↗
Continuous caudal anaesthesia with chloroprocaine as an adjunct to general anaesthesia in neonates.
PURPOSE: The authors prospectively evaluated the use of a continuous caudal epidural infusion of chloroprocaine as an adjunct to general anaesthesia during intra-abdominal surgery in neonates. CLINICAL FEATURES: The technique was used in 25 neonates ranging in age from 1 to 28 days and in weight from 2.2 to 4.9 kg. Following anaesthetic induction and tracheal intubation, an initial bolus dose of chloroprocaine 3% (1 or 1.5 ml.kg-1) was followed by a continuous infusion of 1 or 1.5 ml.kg-1.hr-1 administered through a caudal epidural catheter. No parenteral opioids were administered. The duration of the surgical procedures varied from one hour five minutes to three hours 15 min. The first three neonates received a bolus dose of 1.0 ml.kg-1 followed by an infusion of 1.0 ml.kg-1.hr-1 chloroprocaine 3%. These three neonates required an additional bolus dose followed by an increase in the infusion to 1.5 ml.kg-1.hr-1 to provide surgical anaesthesia. Adequate intraoperative anaesthesia was achieved in all 25 neonates with an infusion of 1.5 ml.kg-1.hr-1 of chloroprocaine 3%. This was evidenced by a lack of haemodynamic response to surgical manipulation. No neonate required more than 0.2% isoflurane or 70% nitrous oxide in oxygen. No episodes of haemodynamic instability (decreased blood pressure/bradycardia) related to the caudal epidural anaesthesia were noted. Twenty-three of 25 of the neonates' tracheas were extubated immediately (within 10 minutes) following the surgical procedure. CONCLUSIONS: Caudal anaesthesia with a continuous infusion of chloroprocaine can be used as an adjunct to general anaesthesia during abdominal surgery in neonates. Our initial experience suggests that the combined technique may eliminate the need for parenteral opioids and limit the intraoperative requirements for inhalational anaesthetic agents.
Anesthesia, Caudal↗
Laparoscopic evaluation for contralateral patent processus vaginalis: Part II.
Between May 1,1992 and August 1, 1995, 599 consecutively treated children under 10 years of age evaluated by the authors for a known inguinal hernia were involved in a prospective protocol to determine whether diagnostic laparoscopy has a place for evaluation of the contralateral inguinal region. The experience with the first 221 patients was reported at the 1993 AAP meeting. In this total experience, 81 patients had known bilateral inguinal hernias and did not require diagnostic laparoscopy. Five hundred eighteen patients had a unilateral inguinal hernia with the status of the contralateral region being unknown. Between May 1, 1992 and May 1, 1994, 368 children underwent evaluation using an umbilical approach. However, for the past 14 months, 150 patients have undergone the diagnostic laparoscopy through the ipsilateral hernia sac. Among the children under 1 year of age, 98 were found to have a unilateral hernia and also a contralateral patent processus vaginalis (CPPV) and 110 had a unilateral hernia. Of the children older than age 1,116 had a unilateral hernia and CPPV and 194 had only a single hernia. After induction of anesthesia, it was suspected on clinical examination that 195 of the 518 patients had a CPPV. However, laparoscopy showed that only 94 (48%) had a CPPV. In the remaining 323 patients, the surgeon believed that a CPPV was not present based on the examination. This negative finding was verified in only 198 patients (81%), but a surprising 125 (39%) did have CPPV documented at the time of endoscopy. Insufflation alone was very unrellable for documenting the presence of CPPV. Of the 214 patients for whom CPPV on the contralateral side was documented during laparoscopy, only 41 (19%) had a positive finding on insufflation. This experience has convinced the authors that diagnostic laparoscopy is the most accurate means to ascertain whether a patient should undergo contralateral inguinal exploration. In addition, laparoscopy through the ipsilateral inguinal sac is now the preferred approach.
Female↗
Laparoscopic esophagomyotomy for achalasia in children.
Achalasia is an uncommon condition in children. The authors report on two children who were evaluated and treated with laparoscopic esophagomyotomy. A 6-port technique was used, with five 5-mm ports and one 10-mm port. During the procedure, esophagoscopy was performed simultaneously, which provided esophageal distension for easier dissection and aided the surgeon by documenting when a complete myotomy had been accomplished. The patients' symptoms have resolved, and no postoperative complications have developed. Laparoscopic esophagomyotomy can be performed safely in children and is an effective approach for treatment of this disorder. Its advantages over the open approach include shorter hospitalization and less discomfort.
Adolescent↗
General anesthesia using the laryngeal mask airway during brief, laparoscopic inspection of the peritoneum in children.
The authors prospectively examined the cardiorespiratory changes seen with general anesthesia using the laryngeal mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. Anesthesia consisted of halothane in 50% oxygen/air and a caudal epidural block. The patient was allowed to ventilate spontaneously without assistance. Baseline measurements of heart rate, systolic blood pressure (SBP), end-tidal CO2 (ETCO2), tidal volume, respiratory rate, and oxygen saturation were recorded every 1 min for 5 min prior to the start of laparoscopy and every minute during the laparoscopic procedure. A total of 15 patients were enrolled in the study ranging in age from 15 to 90 months (35.5 +/- 23.8 months) and in weight from 10 to 26.4 kg (14.9 +/- 4.9 kg). The length of the laparoscopy varied from 3 to 9 min (6.1 +/- 2.1 min). Although clinically insignificant, there was an increase in the heart rate from a baseline value of 141 +/- 9 to 148 +/- 9 beats/min (p = 0.0016) and in the SBP from a baseline value of 97 +/- 6 mm Hg to 101 +/- 7 mm Hg (p = 0.0087). The baseline tidal volume prior to the start of laparoscopy was 5.2 +/- 1.1 mL/kg and increased to 6.4 +/- 1.4 mL/kg during laparoscopy (p < 0.0001) while the respiratory rate increased from 32 +/- 4 to 40 +/- 6 breaths/min (p < 0.0001). ETCO2 increased from a baseline value of 47 +/- 6 to 53 +/- 6 torr (p = 0.0059). The maximum value of the ETCO2 was 55 torr or greater in 6 patients, exceeded 60 torr in 3 patients, with a maximum value of 63 torr. The increased ETCO2 returned to baseline within 2 to 7 min (4.7 +/- 1.5 min) following completion of the laparoscopy. There was no significant change in oxygen saturation. Our initial experience suggests that general anesthesia may be provided using the laryngeal mask during brief laparoscopic inspection of the peritoneum.
Anesthesia, General↗