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Biomedical subjects

G W Holcomb

Publications and source records attributed to G W Holcomb.

At least 55 records · Page 3Linked to original sources
PubMed1996

The use of laparoscopy in the management of the nonpalpable testis.

Fifty-eight children with a nonpalpable testis have been evaluated at our institution between 1988 and 1994. Laparoscopy was performed in these children to effect a treatment plan. The children range in age from 10 months to 14 years. Thirty patients had a nonpalpable left testis, 18 had a nonpalpable right testis, and 10 had bilateral nonpalpable testes. In 28 children, a testis was visualized. Two underwent laparoscopic orchiectomy and 26 underwent either a standard single stage procedure (11), a staged open procedure (3), or a laparoscopically assisted staged procedure (12). Attenuated vessels were seen in 26 patients and inguinal exploration revealed a viable testis in 6 patients and a testis remnant, which was removed, in 20 patients. Four patients had laparoscopic blind-ending vessels. Diagnostic laparoscopy affords the surgeon not only the ability to localize the testis with virtual certainty, but also the advantage of planning a highly successful treatment program. The position of the testis intra-abdominally and the length of the spermatic vessels can be easily evaluated to decide whether a staged approach versus a single stage procedure can be performed. The use of the KTP laser has made the two staged procedure quite easy with only one Trocar site necessary. This experience has allowed us to develop and modify an algorithm for the effective management of the nonpalpable testis.

Adolescent↗
PubMed1995

Minimally invasive surgery in children with cancer.

BACKGROUND: The safety and efficacy of minimally invasive oncologic procedures in children have not been well defined and only limited anecdotal experience has been published. METHODS: A retrospective review of all patients undergoing either a laparoscopic or thoracoscopic procedure at Childrens Cancer Group institutions between December 1, 1991, and October 1, 1993, was performed. RESULTS: Eighty-five children underwent 88 minimally invasive surgical procedures as part of the evaluation or treatment for cancer at 15 participating centers. In 25 patients, laparoscopy was performed and 60 patients underwent 63 thoracoscopic operations. Tissue biopsies were taken in 67 cases and diagnostic material was obtained in 99% of the biopsies. Seven complications occurred, all within the thoracoscopic group. These included conversion of six operations to an open procedure. One patient developed atelectasis postoperatively. CONCLUSIONS: In pediatric patients with suspected cancer, laparoscopy was highly accurate with minimal morbidity; thoracoscopy was nearly as efficient with slightly higher morbidity. Both modalities are useful for assessment of resectability, for staging purposes, and for evaluation of recurrent or metastatic disease.

Adolescent↗
PubMed1995

Laparoscopic and thoracoscopic assistance with CSF shunts in children.

Between June 1992 and June 1994, six children underwent laparoscopic or thoracoscopic assistance in the management of cerebrospinal fluid (CSF) shunts. Four children (3 to 12 years of age) required laparoscopic assistance. Two children (5 and 10 years of age) underwent thoracoscopy with insertion of syringopleural shunts for decompression of cervicothoracic hydromyelia. Most children who require CSF decompression do not need endoscopic assistance for placement of the terminal portion of the shunt. However, in selected patients who have undergone previous abdominal procedures, in patients with a persistent pseudocyst occupying an extensive portion of the abdominal cavity, and in patients requiring removal of a disconnected shunt, laparoscopy is the ideal approach. Thoracoscopy for a syringopleural shunt prevents the need for minithoracotomy.

Cerebrospinal Fluid Shunts↗
PubMed1995

Cardiorespiratory changes in children during laparoscopy.

The authors prospectively examined the cardiorespiratory changes during brief laparoscopy (less than 15 minutes) in children. Intraoperative ventilatory management included a tidal volume of 12 mL/kg, with the rate adjusted to achieve an end-tidal CO2 (PETCO2) of 30 to 35 mm Hg. The initial rate and tidal volume were not changed during the procedure. Baseline measurements of heart rate, blood pressure, peak inflating pressure (PIP), PETCO2, and oxygen saturation were recorded every minute for 5 minutes before the start of the laparoscopic procedure, and every minute during the laparoscopic procedure. Fifty-five patients were enrolled in the study (age range, 1 month to 7 years; weight range, 5.2 to 31 kg). PIP increased from the baseline value of 20 +/- 2.5 to 23 +/- 3.2 cm H2O (P < .01) during laparoscopy. The increase in PIP was 5 or more in six patients, with a maximum of 7. PETCO2 increased from the baseline value of 32 +/- 3.1 to 35 +/- 4.8 mm Hg (P < .01). The PETCO2 returned to baseline within 10 minutes after completion of the laparoscopy. No increase in ventilatory parameters was required during the brief laparoscopic procedure.

Blood Pressure↗
PubMed1994

An alternative technique for laparoscopic cholangiography.

The current methods utilized for laparoscopic cholangiography involve cystic duct cannulation and present practical difficulties and potential hazards. An alternative method for intraoperative cholangiography is described which is easy, quick, and safe. The Kumar clamp (a gift from Sabi Kumar, M.D.) is placed across the infundibulum. A 23-gauge sclerotherapy needle is introduced through a side port in the clamp and directed into the infundibulum. The cholangiogram is obtained prior to any dissection in the triangle of Calot, thereby avoiding iatrogenic common bile duct injuries due to misidentification of the cystic duct or anomalous anatomy. To date no pathology has been missed and no complications have resulted from this technique.

Acute Disease↗
PubMed1994

Laparoscopic cholecystectomy in infants and children: modifications and cost analysis.

Between June 1990 and February 1993, 26 children underwent laparoscopic cholecystectomy. Their ages ranged from 25 months to 19 years (mean, 12.3 years; median, 13 years). Only six of them had hemolytic diseases associated with gallstones. Five presented with acute cholecystitis. Laparoscopic cholecystectomy was performed on these five, within 5 days of admission; the mean postoperative hospital stay was 2.5 days. The other 21 patients underwent elective cholecystectomy; their mean postoperative stay was 1 day. Several modifications have been made in our technique. Three 5-mm ports and one 10-mm umbilical port are used. In addition, direct incision of the umbilical fascia is performed with insertion of a blunt trocar and cannula rather than using the Veress needle for insufflation. The importance of positioning the epigastric cannula in the left upper quadrant in small children cannot be overemphasized. Cholangiography is now attempted in all patients and is easier with the Kumar cholangioclamp and sclerotherapy needle, under fluoroscopy. The total hospital charges for the patients who underwent elective laparoscopic cholecystectomy are compared retrospectively with those of seven children who had elective open cholecystectomy during the same period. In addition, a comparison is made between the two groups with respect to the costs of operating room equipment and postoperative pain control.

Child↗
PubMed1994

Laparoscopic evaluation for a contralateral patent processus vaginalis.

Between May 1, 1992 and March 1, 1993, 221 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. Twenty-six had known bilateral inguinal hernias and did not require diagnostic laparoscopy. Of the other 195 children who underwent laparoscopy before hernia repair, 86 had a unilateral hernia with a contralateral patent processus vaginalis (CPPV), and 109 had only a unilateral hernia. After anesthesia, it was suspected on prelaparoscopic clinical examination that 55 patients had a CPPV. During laparoscopy, it was noted that 31 (56%) had patent processus vaginalis and 24 (44%) did not. Of the 140 patients believed to have a CPPV on prelaparoscopic clinical examination, 60 (43%) did and 80 (57%) did not. Insufflation alone was not diagnostic of CPPV; of the 195 patients undergoing laparoscopy, insufflation resulted in a positive finding on the known side in only 129 (66%) and on the contralateral side in 23 of the 86 patients (27%) found to have a CPPV. There were no complications related to the laparoscopy or the hernia repair.

Child↗
PubMed1994

Laparoscopic cholecystectomy in infants.

Laparoscopic cholecystectomy has become the standard of care for cholecystectomy in adults and is rapidly gaining acceptance in children. However, its use in small children and infants had not been reported. Three young children (10, 15, and 25 months of age) underwent laparoscopic cholecystectomy without complication. Each child was discharged the morning after the procedure. No complications have been noted throughout the follow-up periods (2 months, 18 months, and 4 months, respectively).

Child, Preschool↗
PubMed1994

Outcome of cardiovascular collapse in pediatric blunt trauma.

STUDY OBJECTIVES: To determine the survival and functional outcome of pediatric blunt trauma victims demonstrating cardiovascular collapse, including pulseless cardiopulmonary arrest or severe hypotension, on initial presentation in an emergency department. DESIGN: Seven-year consecutive case-control series. SETTING: Level I trauma center and university teaching hospital. PARTICIPANTS: Two thousand one hundred twenty consecutive pediatric victims of blunt trauma less than 16 years old admitted to a Level I trauma center from August 1984 through December 1991 had a mortality of 5.2%. Thirty-eight patients (1.8%) demonstrated pulseless cardiac arrest or severe hypotension (systolic blood pressure of 50 mm Hg or less) on initial presentation in the ED. INTERVENTIONS: All patients received basic and advanced life support consistent with guidelines published by the American Heart Association, American Academy of Pediatrics, and American College of Surgeons. MEASUREMENTS AND MAIN RESULTS: Survival, functional outcome, and donor status were reviewed. Outcome of ED resuscitation (death or reanimation), post-ED destination (morgue, operating room, or pediatric ICU) length of hospitalization, functional outcome after hospital discharge, time to death (time from admission to ED to declaration of death), cause of death, total hospital costs, total hospital charges, and organ donation were reviewed. There were no functional survivors among 38 pediatric victims of blunt trauma who presented to the ED in pulseless cardiac arrest or with severe hypotension. Eleven of the 12 patients who were transferred to the pediatric ICU died; the single survivor demonstrated profound neurologic impairment six years after hospitalization. Six of these 12 patients were eligible potential donors and resulted in four multiorgan donors during the seven-year study. The mean hospital unreimbursed care for the 38 study patients was $3,514 per patient. CONCLUSION: No child who presented with pulseless cardiac arrest or severe hypotension following blunt trauma achieved functional survival. Reimbursed care for pediatric victims of blunt trauma demonstrating cardiovascular collapse is disproportionately poor compared with that for pediatric patients who maintain hemodynamic integrity in the ED. Half of all patients who were stabilized sufficiently for transfer to the pediatric ICU were eligible potential organ donors. Therefore aggressive resuscitation of these patients may be justified if organ donation is seriously contemplated and aggressively pursued.

Adolescent↗
PubMed1994

Caudal epidural block for analgesia following herniorrhaphy with laparoscopy in children.

This study prospectively evaluated the efficacy of caudal epidural block in providing analgesia following inguinal herniorrhaphy and laparoscopy. Laparoscopy was used only to inspect the contralateral side to determine if a second hernia was present. No surgical manipulation was performed through the telescope. Following mask induction with halothane in nitrous oxide and oxygen, a caudal epidural block was performed with 1.2 mL/kg of 0.25% bupivacaine. Pain scores were obtained at four points during the in-hospital postoperative course, and the need for supplemental analgesic agents was assessed. A total of 45 patients were studied. Caudal epidural block could not be performed in 1 patient, and this patient was excluded from further consideration. There were 34 boys and 10 girls, ranging in age from 2 to 84 months (mean +/- SD 37.4 +/- 18.2 months) and weighing from 3.4 to 34 kg (mean +/- SD 14.2 +/- 5.8 kg). Thirty-six of 44 patients (82%) did not require supplemental analgesic agents during their in-hospital postoperative course and had pain scores of 2 or less at all four evaluation points. Six of 8 patients required a single dose of intravenous fentanyl (0.5 microgram/kg) to maintain scores of 2 or less. No significant complications related to caudal epidural block were noted in any patient. Caudal epidural block provides effective analgesia following inguinal herniorrhaphy and laparoscopy in children.

Analgesia, Epidural↗
PubMed1994

General anesthesia by mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children.

We prospectively examined the cardiorespiratory changes seen with general anesthesia by mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. Anesthesia consisted of isoflurane in 50% oxygen/air and a caudal epidural block. The patient was allowed to ventilate spontaneously without assistance. Baseline measurements of heart rate, systolic/diastolic blood pressure (BP), end-tidal CO2 (PETCO2), tidal volume, respiratory rate, and oxygen saturation were recorded every 1 min for 5 min before the start of laparoscopy and every minute during the laparoscopic procedure. A total of 20 patients were enrolled in the study, ranging in age from 15 to 80 months (mean 40.8 months) and in weight from 10.5 to 27 kg (mean 15.9 kg). The length of the laparoscopy varied from 3 to 18 min (mean 6.9 min). No significant changes (increase or decrease of 20% from baseline) of heart rate or BP occurred. Oxygen saturation remained at 98%-100% throughout the procedure in all patients. The baseline tidal volume before the start of laparoscopy was 6.27 +/- 1.9 mL/kg and increased to 7.3 +/- 2.2 mL/kg during laparoscopy (p = 0.01). The baseline respiratory rate was 27.7 +/- 7.0 breaths/min and increased to 33.5 +/- 7.2 breaths/min during laparoscopy (p = 0.0001). PETCO2 increased from a baseline value of 37.5 +/- 6.5 to 44.6 +/- 6.8 mm Hg (p = 0.0001). The increase in PETCO2 was 10 or greater in 3 patients and exceeded 50 mm Hg in 3 patients, with a maximum value of 66 torr.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, General↗
PubMed1994

Laparoscopy for the nonpalpable testis.

Between 1988 and 1992, 287 infants and children have been evaluated for an undescended testis. In 35, the testis was not palpable. These 35 patients ranged in age between 10 months and 14 years, with a mean of 44 months and a median of 15 months. Thirteen patients had a nonpalpable right testis, 18 had a nonpalpable left testis, and four had bilateral nonpalpable testes. Diagnostic laparoscopy was performed in these 35 boys with a nonpalpable testis to allow a planned approach to management of this condition. In 11 children, a testis was visualized. The testis was in an inguinal hernia sac in seven, and single stage conventional orchiopexy was performed. In four children an intra-abdominal testis was seen, and three infants underwent laparoscopic clip ligation of the testicular vessels. One teenager underwent orchiectomy. In 21 of the remaining 24 boys, small, attenuated testicular vessels were noted to pass into the inguinal canal and inguinal exploration was required. A small testicular remnant was excised in 15 patients, but orchiopexy was possible in six boys. Diagnostic laparoscopy takes 7 to 10 minutes and enables the surgeon to develop a planned approach to this condition. With the information gathered at laparoscopy, the surgeon is best able to decide if an inguinal exploration is necessary or if a single-stage orchiopexy is possible. If a two-stage orchiopexy is required for an intra-abdominal testis, then clip ligation of the testicular vessels can be performed laparoscopically as the first stage, followed by Fowler-Stephens orchiopexy 6 to 9 months later.

Adolescent↗
PubMed1993

Thoracic epidural anaesthesia in infants and children.

When compared with conventional analgesic techniques, epidural anaesthesia not only provides improved analgesia, but also has several beneficial effects on the postoperative respiratory, cardiovascular, and metabolic status of the patient. Although the efficacy and safety of caudal and lumbar epidural anaesthesia in children has been demonstrated, there is little information concerning the use of thoracic epidural anaesthesia. The purpose of our review was to evaluate the safety of thoracic epidural anaesthesia in infants and children. We retrospectively reviewed our three-year experience with thoracic epidural anaesthesia for postoperative analgesia in children. Epidural catheters were placed at the thoracic level without difficulty in 63 children ranging in age from three months to 18 yr and in weight from 3.2 to 78 kg. Postoperative analgesia was provided by the continuous infusion of a bupivacaine/fentanyl mixture, supplemented with intermittent epidural fentanyl by bolus as needed. Epidural catheters were successfully placed in all patients. No inadvertent dural punctures were noted. No episodes of respiratory depression related to epidural analgesia occurred. Minor adverse effects including pruritus occurred in six patients, three of whom required pharmacological intervention with diphenhydramine. Our review suggests that this is a safe and effective method of postoperative analgesia following thoracic surgery in children.

Adolescent↗
PubMed1993

Pediatric laparoscopic splenectomy.

We report our initial experience and describe the operative technique used in three patients who underwent laparoscopic splenectomy for hematologic disorders between September 1991 and February 1992. No early or late complications have been found at an average follow-up of 9 months. All have remained asymptomatic and continue to have normal cell counts. We believe that splenectomy is a feasible extension of minimally invasive surgery in the hands of experienced surgeons. However, recognition of its limitations and ability to convert to the open procedure to assure safe excision is essential.

Adolescent↗
PubMed1993

Survival after gastrointestinal perforation from esophageal atresia and tracheoesophageal fistula.

Management of premature infants with esophageal atresia (EA), tracheoesophageal fistula (TEF), and respiratory distress syndrome (RDS) can be one of the most challenging aspects in the surgical care of the newborn. Although not common, there have been reports of EA, TEF, and RDS with gastric perforation, but an associated duodenal perforation has not been reported. Two premature infants weighing less than 1,200 g with EA, TEF, and perforation are described. One baby developed a gastric perforation and the other a duodenal perforation. Emergency thoracotomy and fistula ligation were necessary after gastrostomy placement. These patients are the smallest infants reported to survive gastrointestinal perforation complicated by EA, TEF, and RDS.

Duodenal Diseases↗
PubMed1993

Fatal hemorrhage caused by disease progression after partial splenectomy for type III Gaucher's disease.

An 18-month-old boy with Gaucher's disease, massive hepatosplenomegaly, and hypersplenism underwent partial (85%) splenectomy and recovered without complication. During the next 4 months, his residual splenic segment showed progressive enlargement from 2 to 6 cm below the left costal margin. By this time, genetic typing had indicated central nervous system involvement (type III). A compatible donor was not available for bone marrow transplantation. Complete splenectomy was not recommended despite continued enlargement of the organ into the pelvis and across the abdominal midline by 7 1/2 months postoperatively. The next week he presented to the emergency room in shock with an hematocrit of 6% and a platelet count of 18,000/mm3. During emergency surgery, massive intraabdominal hemorrhage was noted from a splenic rupture on the inferior pole that was opposite the site of prior division. He died in the operating room during attempted splenectomy. This is a report of fatal outcome after partial splenectomy for type III Gaucher's disease. Patients with subacute neuronopathic disease may not be candidates for subtotal splenectomy.

Fatal Outcome↗