Abdominal Surgery In Children Research Articles

Effect of epidural clonidine on minimum local anesthetic concentration (ED50) of levobupivacaine for caudal block in children

Clonidine has the potential to significantly prolong the duration of caudal epidural anesthesia. We investigated the effect of the addition of clonidine to the MLAC of levobupivacaine in a randomized controlled dose-response trial. A group of 120 children aged <6 years of age received caudal anesthesia with levobupivacaine and 1, 2, or 3 μg·kg(-1) of clonidine. The MLAC was determined according to a Dixon-Massey protocol. The primary outcome was effective surgical anesthesia. Secondary outcomes were the duration of postoperative analgesia, postoperative pain scores, clonidine side effects, and time to hospital discharge. The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and 0.035% with 1, 2, and 3 μg·kg(-1) of clonidine, respectively. There were significant dose-dependent increases in median duration of analgesia. The incidence of delayed discharge, somnolence, and PONV was significantly increased in the 3 μg·kg(-1) of clonidine group. Clonidine produces a local anesthetic sparing effect with a dose-dependent decrease in levobupivacaine MLAC for caudal anesthesia. In addition, there is a dose-dependent prolongation of postoperative analgesia following lower abdominal surgery in children. A dose of 2 μg·kg(-1) of clonidine provides the optimum balance between improved analgesia and minimal side effects.

Efficacy of postoperative epidural analgesia in adolescent scoliosis surgery: a meta‐analysis

Scoliosis surgery is one of the most painful operations performed. Postoperative pain management has been historically based on the use of intravenous opioids. Many of the adolescents who undergo these procedures are at increased risk for opioid-related side effects because of underlying medical problems. Epidural analgesia has been demonstrated to provide superior pain control with fewer side effects for chest and abdominal surgery in children as well as adults. We aim to analyze the available literature for sufficient evidence to allow recommendations regarding the use of epidural analgesia with parenteral opioids vs. intravenous opioids only. Public Medline and the Cochrane database were searched (1966-10/2008) using scoliosis-related and epidural analgesia-related terms. In Medline, the intersection of these results was combined with Phases 1 and 2 of a highly sensitive search strategy recommended for identifying randomized trials. No limits were used in any search. Additionally, professional journals and proceedings of meetings were screened, and nationally recognized experts in the field of pediatric pain management were asked for further sources of data. Randomized, controlled trials comparing the use of a continuous infusion of epidural local anesthetics plus intravenous opioids vs. intravenous opioids only for postoperative pain management in adolescent scoliosis repair were eligible for inclusion in the meta-analysis. All studies had to include at least the primary outcome of interest, postoperative pain scores. After the development of a data collection and extraction form, two independent reviewers extracted all. No data conflicts were encountered. Data were analyzed with Review Manager when possible, significance for difference between relative rates between groups was analyzed by chi-square tests. Average pain scores were lower in the epidural group than no epidural group at 24, 48 and 72 h after surgery. Pain scores (0-100) were lower on all first three postoperative days (POD) in the epidural group: -15.2 on POD1, -10.1 on POD2 and -11.5 on POD3. Differences were significant in the summary analysis for all 3 days (P < 0.05). Epidural analgesia is beneficial to patients in terms of improving pain control and reducing side effects. The influence on respiratory depression, length of stay in the intensive care unit, or mortality is not available in the literature at this time.

Need for Thiamine in Peripheral Parenteral Nutrition After Abdominal Surgery in Children

Thiamine blood concentrations of pediatric patients receiving peripheral parenteral nutrition change during the postoperative period. In addition, the need to administer thiamine after surgery has not yet been fully studied in children receiving peripheral parenteral nutrition. The objective of this prospective study is to clarify whether pediatric patients require the administration of thiamine while receiving peripheral parenteral nutrition after abdominal surgery. Fifteen children were divided into 2 groups; 1 group received peripheral parenteral nutrition without thiamine after surgery (n = 7), whereas the other group received peripheral parenteral nutrition with thiamine after surgery (n = 8). In both groups, thiamine blood concentrations were measured on the preoperative day, and changes in thiamine concentration over time were measured during the starvation period from the first to the fifth postoperative day. Preoperative thiamine blood concentrations were within the normal range in both groups. In the group receiving peripheral parenteral nutrition without thiamine, the thiamine concentration gradually decreased with time after the operation, whereas the concentration remained within the normal range in the group receiving peripheral parenteral nutrition with thiamine. Among the 7 patients receiving peripheral parenteral nutrition without thiamine, the thiamine concentration in 3 patients was below the normal range on the fifth postoperative day. During the starvation period after abdominal surgery, thiamine blood concentrations decreased in pediatric patients receiving peripheral parenteral nutrition without thiamine. Therefore, clinicians treating pediatric patients should add thiamine to the peripheral parenteral nutrition solution during the short starvation period after abdominal surgery.

Fat-containing lesions revealed by CT in children with right lower quadrant pain

Suspected appendicitis is the most common indication for emergent abdominal surgery in children. The clinical diagnosis of appendicitis can be challenging, and CT is playing an increasing role in the evaluation of right lower quadrant pain. Occasionally, alternative diagnoses to appendicitis can be suggested on CT. The appreciation of a fat-containing lesion in the right lower quadrant will often allow a specific diagnosis. Importantly, many of these lesions are self-limited and treated nonoperatively. The purpose of this pictorial essay is to illustrate the spectrum of fat-containing lesions that can present as alternative diagnoses to appendicitis on CT scans performed for the evaluation of right lower quadrant pain in children.

Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review

Chylous ascites (CA) is an extremely rare complication of abdominal surgery in children. This report describes a 4-month-old girl with malignant rhabdoid tumor of the kidney (MRTK), who developed CA after left nephrectomy without lymphadenectomy, and who was successfully treated conservatively with enteral therapy. The literature on CA after nephrectomy without lymphadenectomy for MRTK is reviewed herein, and the clinical problems of postoperative CA are discussed.

Adhesions after abdominal surgery in children

Adhesions after abdominal surgery in children

Intravenous fluids warming by mattress is simple and efficient during pediatric surgery

Background/Aim: Temperature control is essential during pediatric surgery. The effectiveness of two methods of warming intravenous (i.v.) fluids to preserve normothermia was compared during abdominal surgery. Methods: Intraoperative core temperature (CT) was measured in 59 children, 8 years of age and younger. Patients were randomly allocated to two study groups according to the method of fluids warming. In Group M (n = 30), fluids were warmed by placing the i.v. tubing under a warming mattress, and in Group T (n = 29), by using an active i.v. fluid tube warming system. Observations of CT, infusion fluid temperature (IFT) at the entry to the patient and other relevant parameters were made at 30-min intervals throughout the surgical procedure. Results: The two groups did not differ significantly by age, gender, body weight or length of surgical procedure. Although baseline IFT was significantly lower in Group M than in Group T (33.8 °C vs. 35.1 °C), it increased during the procedure by 1.2 °C in Group M compared to a 0.2 °C increase in Group T. Baseline CT was also lower by 0.5 °C in Group M compared to Group T (NS), but CT increased in Group M by 1.0 °C compared to 0.2 °C in Group T, resulting in similar final CTs. Conclusions: The increase in CT was more pronounced in patients where fluids were warmed under the warming mattress (Group M) than in those with fluids warmed by a coil warming device (Group T). The elevation in CT seen in Group M is associated with an increase in infusion fluid temperature at the line just before the i.v. cannula. Both methods of fluid warming (by placing the i.v. tubing under warming mattress and by using a fluid warming system) effectively preserved normothermia during abdominal surgery in children.

Influence of Gum Chewing on Return of Gastrointestinal Function after Gastric Abdominal Surgery in Children

The study was designed to investigate the influence of gum chewing on the return of gastrointestinal function after gastric abdominal surgery in children and the action of neural and humoral hormones in the mechanism of gum chewing. Eighteen patients were enrolled in our study. Each patient underwent gastrointestinal surgery and was then randomly assigned to either the gum-chewing or the control group. The patients in the gum-chewing group chewed gum three times a day in the morning, the afternoon and the evening from the first postoperative morning until the day they began oral intake. The time of first passage of flatus was recorded to evaluate the return of bowel movement. Blood samples were taken immediately after the 3rd gum chewing for the analysis of gastrin and catecholamines (epinephrine, norepinephrine). The first passage of flatus in the gum-chewing group was seen on average of 69 h after operation, which was significantly earlier than the average of 77 h in the control group (p < 0.05). However, in contrast to the time of first flatus, the values of blood catecholamines and gastrin showed no significant difference between the two groups. Gum chewing hastens the return of intestinal function after gastric abdominal surgery in children. The mechanism by which gum chewing initiates an earlier return of gastrointestinal function is still unknown, although neural and humoral hormones are presumed to be mediators in stimulating bowel motility.

Laparoscopic versus open abdominal surgery in children with sickle cell disease is associated with a shorter hospital stay

Limited information exists comparing the post-operative complication rate of laparoscopic or open abdominal surgeries in children with sickle cell disease (SCD). The primary objective of this study was to compare the outcomes in children with SCD who required laparoscopic or open abdominal surgery for a cholecystectomy or splenectomy. We conducted a retrospective analysis of laparoscopic and open abdominal surgeries performed in children with SCD (ages 0-20 years) at two medical centers from 1984 to 2004. The primary outcome measures were the rates of post-operative pain and acute chest syndrome (ACS) episodes following laparoscopic or open abdominal surgery. The secondary outcome was length of hospital stay following surgery. We also examined the potential contribution of pre-operative (transfusion) and intra-operative factors (operating time, estimated blood loss, and end-operative temperature) to post-operative SCD-related complications. A total of 140 cases were identified, 98 laparoscopic and 42 open. Episodes of post-operative pain and ACS episodes were comparable between laparoscopic and open procedures (pain: 4% vs. 3%, P = 0.619; ACS: 5% vs. 5%, P = 0.933). Additionally, laparoscopic surgeries were associated with a significantly shorter hospital stay (2.9 vs. 5.4 days, 95% CI -3.7 to -1.4, P < 0.001). There was no difference in the number of hospital readmissions within 1 month of the surgery. For children with SCD who need a cholecystectomy or splenectomy, laparoscopy is the preferred strategy because of a shorter hospital stay with a similar complication rate compared to open surgeries.

Adhesions after abdominal surgery in children

The objective of this study is to quantify the overall burden (operative and nonoperative) of small bowel obstruction caused by adhesions after laparotomy in children. Data from the Scottish National Health Service Medical Record Linkage database were used to assess risk of an adhesion-related readmission in the 5 years after open abdominal surgery in children and adolescents younger than 16 years from April 1996 to March 1997. A total of 1581 children underwent abdominal surgery (ie, from duodenum downward). Patients undergoing surgery on the ileum had the highest risk of readmission because of adhesions in the subsequent 5 years after surgery (9.2%)--formation/closure of ileostomy had the greatest risk (25%); 6.5% of children were readmitted after general laparotomy, 4.7% after duodenal surgery, and 2.1% after colonic surgery. The incidence of readmissions was 0.3% after appendicectomy. The overall readmission rate was 5.3% (if appendicectomy was excluded) and 1.1% (if appendicectomy was included). This population-based study has demonstrated that children have a high incidence of readmissions owing to adhesions after lower abdominal surgery. The risks are related to the site and the type of the original surgery. The risk of further readmissions was highest in the first year but continued with time. The data enable surgeons to target antiadhesion strategies at procedures that lead to a high risk of adhesions.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident’s training

BackgroundIn 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training.MethodsA retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005.ResultsThe type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates.ConclusionsLaparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.

Population-based analysis of the risk of adhesion-related readmissions after abdominal surgery in children

Purpose The aim of this study was to quantify the risk of adhesion-related readmissions after abdominal surgery in children. Methods This was a population-based study. One thousand five hundred eighty-one children younger than 16 years underwent laparotomy in 1996. Patients were identified from the Scottish Morbidity Records database and followed up for 4 years. Results In children younger than 5 years, 4.2% had a readmission “directly” owing to adhesions. In children younger than 16 years, 1.1% had a readmission directly owing to adhesions. The highest risk of readmission followed surgery on the small intestine (9.3%), followed by abdominal wall surgery (5.8%), duodenal surgery (2.6%), colonic surgery (2.1%), and appendicectomy (0.3%). 55% of all readmissions occurred in the first year. Conclusion There was no difference in readmission rates between younger and older children when comparing the organ on which surgery was initially performed. The highest readmission rate followed small intestinal surgery and the lowest followed appendicectomy. The risk of readmission was highest in the first year.

Decreased monocyte class II MHC expression following major abdominal surgery in children is related to operative stress

Monocyte class II major histocompatibility complex (MHC) expression is necessary for antigen presentation and stimulation of T-cells. The aim of this study was to correlate monocyte class II MHC response to operative stress in children and the possible influence of cytokines in the postoperative period. We studied 21 children undergoing elective abdominal surgery. Operative stress score (OSS) was calculated. Monocyte class II MHC expression was measured preoperatively, immediately after surgery, 24 and 48 h postoperatively, using flow cytometry. Class II MHC is expressed as mean fluorescence intensity (MFI) of monocytes expressing MHC (mean +/- SD). Cytokine levels (interleukins 1ra, 6, and 10, and tumor necrosis factor-alpha) were also measured. Data between time points were compared using repeated measures ANOVA. There was an immediate postoperative decrease in class II MHC expression, with lowest levels 24 h postoperatively (preoperative 50 +/- 23.6, 24 h 18.2 +/- 9.4, P < 0.0001 vs. preoperative). At 48 h there was partial recovery in class II MHC, but levels were still significantly lower than preoperative (23.9 +/- 11.1, P < 0.001). The degree of monocyte depression was related to the magnitude of operative stress. Patients who had OSS <10 displayed some recovery in expression at 48 h 25.5 +/- 11.1), whereas in patients with OSS > or = 10 (severe surgical stress), expression further decreased at 48 h (MFI 14.0 +/- 0.1). There was an elevation of interleukin-1ra in the immediate postoperative period in both groups. There was no elevation in the other cytokines. Abdominal surgery in children decreases monocyte MHC expression. Class II MHC depression was related to magnitude of surgical trauma, implying that more severe immuneparesis follows surgery of greater magnitude. This may predispose to postoperative infection.

Childhood acute appendicitis: Is routine appendicectomy advised?

Acute appendicitis is a common occurrence in children. The current trend is to perform appendicectomy once acute appendicitis is diagnosed. The aim of this study was to evaluate the types of pathology seen in appendices removed for acute appendicitis and correlate them with clinical features. The clinical, operative and histological records of 302 children who had appendicectomy at the Jos University Teaching Hospital from 1995-2003 were retrospectively reviewed. There were 123 (40.7%) boys and 179 (59.3%) girls (m: f = 1: 1.5). Their ages ranged from 2-15 years (median: 12 years). The main symptoms and signs at presentation were right lower quadrant abdominal pain, anorexia, nausea, vomiting, right quadrant tenderness, guarding and rigidity. Clinical impressions included simple acute appendicitis in 260 and perforated appendicitis in 42 patients. Of the 302 children who had clinical diagnosis of acute appendicitis, only 144 (47.7%) were confirmed at histology. Lymphoid hyperplasia was the most common pathology seen in the appendix specimens. The clinical impressions of acute appendicitis made by the surgeon agreed with pathologists' report in 63.9% and disagreed in 36.1% of cases. Negative appendicectomy rate was 52.3%. Although appendicectomy is the most commonly performed emergency abdominal surgery in children, the procedure is still associated with a high negative appendicectomy rate.

The abdominal surgery of children. By L. E. Barrington-Ward, Ch.M., F.R.C.S., Surgeon to the Hospital for Sick Children, Great Ormond Street, and to the Royal Northern Hospital, London. Demy 8vo. Pp. 283 + xiii, illustrated in colour and in black and white. 1928. London: Humphrey Milford. 15s. net

The abdominal surgery of children. By L. E. Barrington-Ward, Ch.M., F.R.C.S., Surgeon to the Hospital for Sick Children, Great Ormond Street, and to the Royal Northern Hospital, London. Demy 8vo. Pp. 283 + xiii, illustrated in colour and in black and white. 1928. London: Humphrey Milford. 15s. net

1 Pain Management: Prospective Study in Postoperative Abdominal Surgery in Children

Introduction: Pain in the postoperative period is a rising concern in paediatrics. Ideal management should be the most effective with minimal adverse effects.

The choice of inhalation anaesthetic for major abdominal surgery in children with liver disease.

Many children with liver disease undergo major abdominal surgery. Maintenance of anaesthesia is thus an important consideration in this surgical population. Despite a comprehensive and painstaking review of the literature, a sound evidence base, on which a choice of inhalation anaesthetic may be made, is lacking due to limited research in these patients. Differences between the more recent agents such as isoflurane, sevoflurane and desflurane are minor. Sevoflurane is favoured in paediatric practice for gaseous induction, but desflurane or isoflurane are marginally the preferred agents for maintenance of anaesthesia in children with liver disease undergoing major abdominal surgery. However, on the evidence that exists, much of it admittedly in animals and in adults, all three are preferable to halothane in this group of patients. More work is needed in this area before sound conclusions can be drawn and one agent proved to be definitely superior to the others.

Acute chest syndrome after abdominal surgery in children with sickle cell disease: Is a laparoscopic approach better?

Background/Purpose: Acute chest syndrome (ACS) is the leading cause of hospitalization and death among patients with sickle cell disease (SCD). Surgery is a risk factor for the development of ACS. It has been suggested that laparoscopic surgery could diminish the risk of sickle-related complications; therefore, more procedures may be encouraged in asymptomatic patients. The goal of the authors was to determine the incidence of postoperative ACS and assess for predisposing factors in all sickle cell patients undergoing abdominal surgery. Methods: A retrospective analysis of all sickle cell patients receiving abdominal surgery (open and laparoscopic) between 1994 and 1998 was conducted. Data pertaining to demographics, perioperative clinical status, postoperative care, and outcome were collected and analyzed using Student's t test or χ2 where appropriate. Results: Fifty-four children underwent 62 procedures (35 abdominal and 27 extracavitary). All abdominal cases were either cholecystectomy or splenectomy (22 laparoscopic and 13 open). ACS occurred in 7 of 62 (11.3%) overall, and all were in abdominal cases 7 of 35 (20%). ACS occurred in 5 of 22 (22.7%) laparoscopic cases and 2 of 13 (15.4%) open cases. Operating time was significantly longer in the laparoscopic group compared with open cases (P <.05). A higher percentage of patients who had ACS had at least 1 previous episode (71.4% v 39.3%; P value not significant) and a smaller percentage of ACS patients received a preoperative blood transfusion (14.3% v 32.1%; P value not significant). Postoperative hospitalization was prolonged if ACS occurred (9 ± 2 v 3 ± 2 days; P <.05). Conclusions: Abdominal surgery carries a significantly high risk (20%) of ACS. Laparoscopy does not decrease the incidence of ACS compared with open approach. Predisposing factors were not significant in predicting postoperative ACS. There is considerable morbidity and potential cost implications in patients with ACS. J Pediatr Surg 36:718-721. Copyright © 2001 by W.B. Saunders Company.

Room H, 10/16/2000 2: 00 PM - 4: 00 PM (PS) Comparison of Three Concentrations of Caudal Ropivacaine for Elective Groin or Lower Abdominal Surgery in Children

<b>Room H, 10/16/2000 2: 00 PM - 4: 00 PM (PS) Comparison of Three Concentrations of Caudal Ropivacaine for Elective Groin or Lower Abdominal Surgery in Children</b>

Is nasogastric tube decompression necessary after major abdominal surgery in children?

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.