Search

BACKGROUND Central lines can be placed through different techniques, either peripherally or centrally. Although they have the same aim, decision to use one of these modalities depends on the patient outcomes. The aim is to compare pain scores between ultrasound-guided central line insertion and peripherally inserted catheter in neonates in a prospective randomized single center study. METHODS A randomized controlled trial was conducted in neonates requiring central venous access for any of the following reasons: total parenteral nutrition (TPN), antibiotics treatment for at least 7 days and having poor or difficult venous access. The study compared pain difference, in neonates, that were randomized between peripherally and ultra-sound guided centrally placed central lines using the validated pain score N - PASS. RESULTS 61 neonates were enrolled in the study. US-guided CICC was associated with less pain as reported by the statistically significant lower pain score difference (p-value

Introduction A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country’s experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones. Method A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients’ characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher’s exact test, as for continuous, Student’s t test was used or one-way ANOVA in case of more than 2 categories. Result Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar. Conclusion In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

Background: Among preterm infants, the peripherally inserted central catheter (PICC) is the standard line for central venous access; however, its placement exposes them to hypothermia and pain. Ultrasound (US)-guided central line insertion may be less morbid than standard PICC line. Aims: To determine the ease, success rate, and morbidity associated with US-guided central line insertion in the internal jugular vein (IJV) by comparing it to the standard PICC line placement. Materials and Methods: This is a single-center nonrandomized prospective study evaluating preterm infants between October 2013 and June 2014. Patients were allocated into two groups: The standard group (control group) who underwent blind PICC line insertion and the intervention group who underwent a percutaneous US-guided central line insertion in the IJV. The epicutaneo-cava-catheter was used in both groups. Results: Fifty neonates were enrolled on study. A statistically difference in favor of US-IJV insertion was noted concerning the rate of successful first attempt (P < 0.001), insertion (P = 0.001), and procedure duration (P < 0.001) and number of trials (P < 0.001) compared to PICC. No difference in complications (P = 1.000) was noted. Conclusion: US guided catheterization of the IJV technique is faster than PICC line insertion with higher rates of successful first attempt and insertion, less procedure duration and fewer number of trials compared to PICC line insertion. There were no differences in complications.

A 4-year-old boy with posterior urethral valves and end stage kidney disease on peritoneal dialysis presented with high pressure non-compliant bladder with left ureterohydronephrosis. Inability to perform hemodialysis due to patient's weight exclusion, imposed the necessity to preserve peritoneal dialysis. A bilateral nephrectomy by retroperitoneoscopy with extraperitoneal augmentation ureterocystoplasty using left ureter and pelvis associated with continent diversion using right ureter as umbilical stoma was performed followed by kidney transplantation. An excellent outcome with voluntary voiding without CIC is reported eighteen months later. This treatment modality is the best option to manage End Stage Kidney Disease on peritoneal dialysis in those patients.

Introduction: Gastric perforation is a potential fatal condition occasionally encountered in adults and neonates but it rarely occurs in children over 1 year of age. We report a case of gastric perforation in a 3 year old boy presenting with surgical abdomen and fever and found to have T cell lymphoma. Case presentation: A 3 years old boy presented after 5 days history of fever for which he …

Pyomyositis is a primary bacterial infection of the skeletal muscles. It is known as tropical myositis as most cases have been reported in patients living in the tropics. However, the disease is increasingly being seen in non-tropical areas, especially in the United States, with little data reported in Lebanon. The disease has a predilection for large muscles especially the quadriceps and gluteal muscles. Pyomyositis is usually diagnosed late, leading to increased morbidity and mortality rates. Time of recognition of the disease directs the course of the treatment. Early diagnosis of pyomyositis, during the pre-suppurative phase, can be treated only with IV antibiotics without the need for surgical incision and drainage. We represent here the case of a 14 year-old male patient who presented with atypical symptoms of fever, dysuria, and abdomino-pelvic pain. Patient was early diagnosed with pomposities of the right obturator muscle with extension to form osteomyelitis of the symphysis pubis. Patient was solely treated for six weeks of Intravenous antibiotics (IV), with full recovery, without the need for surgical drainage.

Background and objective: This study evaluated the accuracy of prenatal MRI and postnatal CT imaging in the identification of congenital cystic adenomatoid malformation and bronchopulmonary sequestration by comparison with histological analysis. Methods: Over a 3-year period, 15 patients with lung malformations diagnosed prenatally by ultrasound were referred for prenatal MRI, and all were investigated postnatally by chest CT. All asymptomatic newborns with unresolved lesions underwent elective surgery by thoracoscopy. All surgical specimens were analysed histologically. Results: Among the 15 patients with an abnormality diagnosed by ultrasound, prenatal MRI findings differed from the final histological diagnosis with respect to extent (n = 3), type of lesion (n = 1) and aberrant vessel identification (n = 4). Postnatal chest CT failed to visualize the aberrant vessel in one patient. Complete regression of the lesion was noted in two patients with bronchopulmonary sequestration, and in one patient with congenital cystic adenomatoid malformation and was confirmed by CT. Elective thoracoscopic lobectomy of the affected lobe was performed for 12 patients. Two conversions to thoracotomy were required. All operated patients had an uneventful hospital course. Conclusions: Prenatal MRI is less accurate than postnatal CT scan, which remains the most reliable diagnostic modality to specify the location and extent and kind of lesions.

Intralobar sequestration (ILS) associated with congenital cystic adenomatoid malformation (CCAM) is a well-known entity. This hybrid form has many considerations for an appropriate management. This report aims to analyze pitfalls in the diagnosis, treatment, and thoracoscopic procedure pertaining to this association.Between May 2004 and September 2007, 23 fetal lung lesions were diagnosed prenatally and managed at the authors' institution. Seven of these lesions were the hybrid form of ILS-CCAM. The records for these lesions were reviewed retrospectively.In all seven fetuses, prenatal ultrasound diagnosed congenital lung abnormalities. In three cases, fetal magnetic resonance imaging (MRI) demonstrated a macrocystic lesion supplied by an aberrant vessel. In all cases, the intrauterine evolution remained uncomplicated. All the newborns were asymptomatic at birth. Chest computed tomography (CT) performed at the age of 1 month showed the aberrant vessel in five cases. A regression of the lesion was noted in one patient and that of the aberrant vessel in another patient. Elective thoracoscopic lobectomy of the affected lobe was performed for six patients. The average age at the time of intervention was 5 months. At this writing, one patient is under observation due to resolution of the lesion. The operating time ranged from 80 to 160 min. One conversion to thoracotomy was required. All surgically treated patients had an uneventful hospital course. Histopathologic examination confirmed the association of intralobar sequestration with Stocker type 2 CCAM in five cases and with CCAM type 1 in one case.Prenatal diagnosis of the ILS-CCAM association was possible, as was resolution of one or both components of this lesion. Preoperative identification of the aberrant vessel is important for prevention of operative morbidity. This should be controlled before the lobectomy is begun.

Laparoscopic mini-gastric bypass (MGB) is being increasingly performed worldwide. Results of MGB by mini-laparotomy (minilap MGB) are hereby reported.126 patients undergoing minilap MGB from October 2004 to October 2006, were reviewed at an academic institution.Mean age was 35 +/- 11.4 years (range 15-72), preoperative BMI was 44 +/- 6.9 kg/m2 (range 35-61.8) and 80 (63.4%) were women. Co-morbidities were present in 42 (33.3%). Operative time was 144 +/- 15.8 minutes (range 120-160) and length of hospital stay was 3.32 +/- 0.62 days (range 2-18). There was no hospital mortality, and the in-hospital complication rate was 4.7%. No anastomotic leakage occurred, and the incidence of wound sepsis was 2.3%. The mean total cost of the procedure was 3408 +/- 547 USD (range 2967-6876). Five patients (3.9%) developed incisional hernias and 3 (2.3%) marginal ulcers. BMI at 6 months was 33.0 +/- 3.1 kg/m2 (range 26.8-43.5, P0.001) compared with preoperative value. At 1 year, mean excess weight loss was 68.4% and comorbidities resolved in 85%.Minilap MGB is a simple, safe, effective and low-cost gastric bypass. It represents an attractive cost-effective alternative to laparoscopic MGB.

Despite the initial success of primary gastric restrictive operations, many patients require revision for weight regain, mechanical complications or intolerance to restriction. The mini-gastric bypass (MGB) for revision of failed primary restrictive procedures was evaluated. 33 patients undergoing revisional surgery to a MGB for a failed silastic ring vertical banded gastroplasty (VBG) or a gastric banding (GB) from June 2005 to September 2006, were reviewed at an academic institution. The patients had had a minilaparotomy. Revision of the VBGs was further compared with revision of the GBs. The MGB was completed in all except 2 patients who required Roux-en-Y gastric bypass (RYGBP) because of gastric tube damage. Mean age was 41 years (range 20–4), preoperative BMI was 39.5 kg/m2 (range 28–8), and 20 (65%) were women. The revision was performed after an average of 36.3 months (range 12–4), and was more time-consuming in patients with prior VBG than GB (184 vs 155 min, P––.007). Postoperative complications occurred in 2 (6.4%) with prior VBG, and length of hospital stay was 4.65 days (range 3–7).Mean BMI at 6 months was 30.6 (range 24.8–0.0, P–lt;–.001) compared with the preoperative BMI. Reflux disease was cured, and all patients noted major improvement in the eating dimension. Open MGB through a previous mini-incision is a safe and effective operation for revision of failed gastric restrictive operations. The revision procedure was technically more difficult in patients with prior VBG and hazardous in patients with prior redo VBG.

We report a covered urethral duplication in a girl presenting prenatally with an enlarged fluid-filled vulvar cyst, genital duplication, and urogenital sinus revealed by fetal magnetic resonance imaging (MRI) and serial ultrasounds. Physical examination revealed an enlarged vulvar mass covering the clitoris, a single orifice, and normally sited anus. Congenital adrenal hyperplasia was ruled out at birth. MRI in addition showed an accessory duct between the sinus and the urine-filled vulvar pouch with a bifid clitoris. A total urogenital sinus mobilization with resection of the accessory urethra and vulvoplasty was performed with uneventful follow-up.

We report the first case in the literature of thoracoscopic bronchial reimplantation in 5 month-old boy. The child was born with congenital cystic adenomatoid malformation of the right lower lobe associated with lower intralobar pulmonary sequestration diagnosed prenatally. An iatrogenic middle lobar bronchus injury was detected per-operatively during thoracoscopic lobectomy. Management and follow-up were exposed.

Acute obstruction of jejunal limbs after gastric bypass surgery is rare but can result in a catastrophic scenario if the diagnosis is delayed. We report a 31-year-old female who developed acute efferent limb obstruction after a laparoscopic mini-gastric bypass (MGB), manifested as recurrent episodes of epigastric discomfort and bile-stained vomiting. The diagnosis was evident on oral contrast studies. She was successfully treated by a salvage laparoscopic side-to-side anastomosis between the efferent limb and the afferent limb 4 cm distal to the gastro-jejunostomy. Acute obstruction of the efferent limb after a MGB operation can be easily diagnosed and effectively treated by laparoscopic latero-lateral jejuno-jejunostomy.

Instrumentation for open surgery has seen relatively little change over the last several decades. Laparoscopic surgery is equipment intensive. Each surgical specialty has different requirements for instruments, and laparoscopic urology involves gaining access, visualization, placement of instruments, dissection and hemostasis of target tissues, extraction of specimens, and wound closure. Adaptations of adult laparoscopic instruments continue to be made for appropriate application and improvement of the safety of laparoscopic procedures in infants and children. This chapter gives an overview of the basic equipment and instruments that should be available.

Recent reports highlight the reduced mortality and morbidity rates of liver resection in the last decades. The authors report on the surgical techniques and perioperative management that have yielded a low mortality and morbidity rates.One hundred consecutive liver resections carried out from 1997 to 2005 were reviewed. Data were collected retrospectively.The indications for liver resection were malignant tumors in 73%. Major liver resection was performed in 52%. Overall, 42.5% of liver resections were performed without vascular clamping and 57% of liver resections were performed without blood transfusions. There was no intraoperative death and the overall mortality rate was 1%. The major complications rate was 28% and was related to the extent of resection. The mean length of hospital stay was 12 days.The current series shows that with accurate preoperative evaluation, standardization of the surgical technique, appropriate use of vascular clamping method, and vigilant postoperative monitoring, an in-hospital mortality of 1% was achieved in a series where more than 50% of patients underwent a major hepatectomy.

To report an uncommon consequence of hepatic artery occlusion in the management of a bleeding pseudoaneurysm following pancreaticoduodenectomy.Analysis of a case involving a single patient in which a bleeding pseudoaneurysm of the gastroduodenal arterial stump following pancreaticoduodenectomy was treated by transcatheter arterial embolization.Effective hemostasis necessitated interruption of the hepatic arterial flow and was complicated by biliary ischemia and intrahepatic biloma.

Smart Zeidan, Rezkalla Akkary, Ramy Ghabril, Nabil Diab and Pauline Abou-Jaoude Department of Pediatric Surgery and Urology, Saint George University Hospital, University of Balamand, Beirut, Lebanon; Department of Clinical Pediatrics and Nephrology, Saint George University Hospital, University of Balamand, Beirut, Lebanon and Department of Clinical Pediatrics and Nephrology, Medical University Center–Rizk Hospital, Beirut, Lebanon

The very large number of procedures described for repairing hypospadias and the very meagre data available on long-term follow-up of these operations are striking evidence of the difficulty of this surgery. The surgeon’s criteria of success may differ quite significantly from the patient’s criteria of satisfaction, as shown in Mureau’s studies (Mureau et al. 1996).

The very large number of surgical techniques described and the inadequate long-term results published for each of them illustrate the difficulty of objective evaluation of hypospadias surgery [9]. Although the majority of surgeons define a satisfactory result as a straight penis without excess skin, regular scars, an apical urethral meatus with a "good" urinary stream, evaluation of these criteria remains very subjective due to the lack of precise, reliable, and standardized methods. The surgeon's criteria of success of this surgery differ significantly from the patient satisfaction criteria [53]. The complication rate reported in the literature therefore varies from 5% to 70% depending on the technique used and the surgeon's honesty.

We report a rare association of complete urethral duplication and exstrophy-epispadias complex in a totally incontinent boy. A voiding cystourethrography was performed and revealed a dorsal epispadiac urethra, a normal ventral urethra, and a good bladder capacity. Urethrocystoscopy showed a normal ventral urethra with verumontanum, normal bladder neck, and a large opening of the dorsal urethra. Dorsal urethral excision and bladder closure were enough to achieve complete continence because of the normal ventral urethra.

Objective To evaluate the effect of the infection and the obstruction of urinary tract on renal parenchyma, we developed a model of ascending urinary infection in mice with partial unilateral obstructive uropathy. Methods Six week-old CBA/J mice were operated on to perform a right partial ureteral obstruction and challenged transurethrally with Escherichia coli CFT073 (high virulent strain) or E. coli Mez (low virulent strain). Level of infection of urine and kidneys, score of inflammation and fibrosis of kidneys, and kidney weight ratio (KWR) in the short and long term were studied. Results At short-term (72 hours) experimentation, partial ureteral obstruction does not influence the level of kidney infection in terms of bacterial count, and the score of inflammation regardless of whether a virulent or low virulent strain was used. At long-term (42 days) experimentation, E. coli Mez was eliminated from all mice kidneys, but CFT073 persisted in almost all; obstruction did not influence the level of kidney infection with CFT073 but a significant difference of KWR and the inflammation and fibrosis score between obstructed and unobstructed kidneys was found ( P = .0078; P = .036, respectively). Although the E. coli Mez strain did not persist in renal parenchyma, severe damage of the renal parenchyma was observed. Conclusion The proposed model is similar to the obstructive uropathy in children in which ureteral obstruction is present before the onset of infection. The association of obstruction and urinary infection impairs kidney growth and favors the occurrence of renal damage.

Objectif Etudier la capacite de l’IRM fœtale de detecter une malrotation intestinale. Materiel et Methodes Etude retrospective sur 5 ans de notre base de donnees d’IRM fœtales non cerebrales. Resultats Quatre cent une IRM fœtales furent analysees. Dans 34 cas (8,5%), le jejunum proximal etait considere en position anormale, cad ailleurs que dans le flanc gauche sous l’estomac sur les sequences ponderees en T 2 . Dans 22 cas (65%), le jejunum etait situe dans l’hemi-thorax gauche dans le cadre d’une hernie diaphragmatique gauche (groupe A). Dans 7 cas (20%) il etait en position extra-abdominale dans le cadre d’un laparoschisis (group B). Dans 5 cas (15%) il etait anormalement situe dans l’abdomen, en position mediane ou dans le flanc droit, avec un estomac en position normale (group C). Tous les cas des groupes A et B ont ete confirmees en periode post-natale ou a l’autopsie. Dans 4 cas du groupe C (syndrome de Prune-Belly, poche colonique, atresie digestive, cardiopathie) la malrotation n’etait pas suspectee en echographie et etait confirmee apres la naissance. Dans le dernier cas, l’intestin etait refoule a droite par une duplication digestive geante, et le TOGD post-natal etait normal. Conclusion Grâce a son excellente resolution en contraste en ponderation T 2 , l’IRM fœtale identifie avec precision une position anormale du jejunum, en dehors de toute suspicion echographique, avec une excellente correlation postnatale.