Publications by authors named "Dragan Kravarusic"

36 Publications

Not only appendicitis: rare appendix disorders manifesting as surgical emergencies in children.

Eur J Pediatr 2021 Feb 18;180(2):407-413. Epub 2020 Aug 18.

Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel affiliated with Sackler Faculty of Medicine, Tel Aviv University, Kaplan St 14, 4920235, Petah Tikva, Israel.

Acute appendicitis is the most common cause of acute abdominal pathology in children. However, other rare non-inflammatory non-neoplastic disorders involving the appendix may manifest as surgical emergencies. This study aimed to describe these atypical entities and present representative cases. The database of a tertiary children's medical center was reviewed for all the patients aged 0-18 years who underwent urgent appendectomy between June 2014 and December 2019, for rare disorders of the appendix unrelated to inflammatory or neoplastic processes. Of 1367 patients who underwent appendectomy, 1345 were operated urgently or emergently. Of these, six, all males, mean age 32.6 months (range 0.7-76), underwent appendectomy for rare surgical complications that involved the appendix. These included torsion of the appendix (2), a strangulated internal hernia through an appendicular ring (1) or through a mesoappendix gap (1), an incarcerated appendix in an acute hernia sac (1), and appendiceal intussusception (1). In all cases, the role of the appendix in the pathologic process was unexpected and came as a surprise to the surgeon. During a median follow-up of 4.2 months (range 1-8 months), one patient underwent relaparotomy for small bowel obstruction 4 weeks after the original procedure.Conclusion: The appendix in children can be the source of rare pathological disorders that present as surgical emergencies. Familiarity with these entities may aid in achieving accurate preoperative diagnosis and contribute to surgical team orientation on exploratory laparotomy. However, correct diagnosis is often only established during timely surgical intervention.
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http://dx.doi.org/10.1007/s00431-020-03784-4DOI Listing
February 2021

Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience.

J Pediatr Surg 2020 Oct 30;55(10):2009-2014. Epub 2020 Jun 30.

Department of Radiology, Soroka Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel.

Background: Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception.

Materials And Methods: This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed.

Results: 414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction.

Conclusion: The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema.

Level Of Evidence: Treatment study level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.05.049DOI Listing
October 2020

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.

Acta Paediatr 2020 08 8;109(8):1672-1676. Epub 2020 Jun 8.

Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Aim: To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID-19 pandemic.

Methods: Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID-19 era and similar period in previous year was performed.

Results: All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID-19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID-19 era compared to similar period in previous year (22% vs 11%, P-value .06).

Conclusion: The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself.
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http://dx.doi.org/10.1111/apa.15376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283758PMC
August 2020

Emergencies in the Treatment of Wandering Spleen.

Isr Med Assoc J 2018 Jun;20(6):354-357

Department of Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Wandering spleen is a rare entity that may pose a surgical emergency following torsion of the splenic vessels, mainly because of a delayed diagnosis. Complications after surgery for wandering spleen may necessitate emergency treatment.

Objectives: To describe the clinical course and treatment for children who underwent emergency surgeries for wandering spleen at a tertiary pediatric medical center over a 21 year period and to indicate the pitfalls in diagnosis and treatment as reflected by our experience and in the literature.

Methods: The database of a tertiary pediatric medical center was searched retrospectively for all children who underwent emergency treatment for wandering spleen between 1996 and 2017. Data were collected from the medical files. The relevant literature was reviewed.

Results: Of ten patients who underwent surgery for wandering spleen during the study period, five underwent seven emergency surgeries. One patient underwent surgery immediately at initial presentation. In the other four, surgical treatment was delayed either due to misdiagnosis or for repeated imaging studies to confirm the diagnosis. Emergency laparotomy revealed an ischemic spleen in all patients; splenectomy was performed in two and the spleen was preserved in three. Four of the seven emergency operations were performed as the primary surgery and three were performed to treat complications.

Conclusions: Wandering spleen should ideally be treated on an elective or semi-elective basis. Surgical delays could be partially minimized by a high index of suspicion at diagnosis and by eliminating unnecessary and time-consuming repeated imaging studies.
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June 2018

Dual versus Triple Antibiotics Regimen in Children with Perforated Acute Appendicitis.

Eur J Pediatr Surg 2018 Dec 25;28(6):491-494. Epub 2017 Sep 25.

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Introduction:  Acute appendicitis is the most common emergency condition in pediatric surgery. Historically, a triple-antibiotic therapy consisted of ampicillin, gentamicin, and clindamycin has been used postoperatively for perforated appendicitis. According to recently published trials, dual therapy consists of ceftriaxone and metronidazole only, offers a more efficient and cost-effective antibiotic management compared with triple therapy. Based on these results, our department applied dual antibiotic therapy for children with perforated appendicitis that underwent appendectomy from 2009 and forth.

Aim:  The aim of our study was to compare postoperative outcomes between patients treated with triple therapy (ampicillin, gentamicin, and metronidazole) (group A) versus dual therapy (ceftriaxone and metronidazole) (group B).

Methods:  Clinical and laboratory data were retrospectively collected by review of the medical records for all children who underwent appendectomy for the perforated appendix at the Schneider Children's Medical Center of Israel, a tertiary pediatric care center between 2007 and 2011. Children with perforated appendicitis received antibiotic therapy in accordance with the hospital's guidelines that were valid at the time the surgery took place. In the first period (years 2007-2009) (group A) a triad of ampicillin, gentamicin, and metronidazole and the second period (2009-2011) (group B) dual therapy consists of ceftriaxone and metronidazole. The two groups were compared for outcome and complications, such as wound infections, changing of antibiotic therapy, and length of stay.

Results:  During the study period 1,203 patients underwent an appendectomy. Of these, 175 patients were diagnosed with perforated appendix and were treated with postoperative antibiotic's regimen. Group A and group B consisted of 89 and 86 patients, respectively. The two groups were not different significantly in terms of demographic data, length of stay, or readmission rates. However, more rates of wound infection and changing of antibiotic therapy were seen in group B, although not statistically significant ( = 0.064).

Conclusion:  Dual antibiotic therapy for perforated appendicitis is a cost-effective and efficient mode of therapy compared with triple-antibiotic's regimen. However, prospective studies are required to determine whether this policy is associated with higher rates of wound infections and change in antibiotic therapy.
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http://dx.doi.org/10.1055/s-0037-1606847DOI Listing
December 2018

[FERTILITY PRESERVATION IN YOUNG CANCER PATIENTS - CAN WE OPTIMIZE THE PATH?]

Harefuah 2017 May;156(5):326-329

Department of Pediatric Oncology, Schneider Children's Hospital, Petah Tikvah.

Introduction: Advances in cancer therapy have improved the long-term survival of cancer patients. Concerns about fertility represent a major issue for young cancer patients. The emergent discipline of oncofertility, an intersection between oncology and fertility, is a new concept that describes an integrated network of clinical resources that focus on fertility preservation from both clinical and research perspectives. Patients and methods: In this article we describe our designated multidisciplinary program for fertility preservation in pediatric and young adult populations. The program is also designed to serve as a prospective platform for the evaluation of reproductive outcomes in this patient cohort.

Results: We have observed considerably higher referral rates following launching the program and earlier referral of chemonaïve patients that concedes maximal fertility preservation. Two hundred and thirty five patients were referred to the program over a period of 3 years.

Conclusions: Our program demonstrates that multidisciplinary programs that encompass relevant specialists, skilled laboratory resources and a facilitated path that drives the process in the shortest time, maximizes the yield.
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May 2017

Point-of-Care Ultrasound in a Department of Pediatric and Adolescent Surgery.

Isr Med Assoc J 2016 Nov;18(11):677-679

Department of Pediatric and Adolescent Surgery, Schneider's Children Medical Center of Israel, Petah Tikva, affiliated with Sacker Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Point-of-care ultrasound (POCUS) is becoming a common tool for routine use in emergency medicine, anesthesiology and intensive care for diagnostic and interventional purposes. When a portable ultrasound device became available for the department of Pediatric and Adolescent Surgery at the Schneider's Children Medical Center of Israel, we added POCUS assessments to the physician's daily rounds. POCUS is performed by pediatric surgeons trained in basic ultrasonography skills. Starting September 2015 all POCUS examinations were documented.

Objectives: To describe the current use, diagnostic and therapeutic impacts of POCUS in a department of pediatric and adolescent surgery.

Methods: We conducted an observational study of all the documented POCUS procedures performed during a half-year period. Data regarding patient condition and the POCUS procedures were collected, as well as data on the use of other diagnostic modalities, mainly formal ultrasound exams (by radiologists) and computed tomography scans and their correlation with the POCUS assessment.

Results: Fifty-one POCUS exams were performed during the study period, most of which served to define the presence and resolution of a collection - intraabdominal (34%) and subcutaneous (31%). Despite a high rate for formal diagnostic studies (65%), probably due to a relative lack of confidence of surgeons performing the POCUS exams during this initial period, most results (92%) were compatible.

Conclusions: The ability and availability to perform multiple POCUS exams by the attending physician proved to be a valuable aide to the classical physical and laboratory examinations of surgical patients, and we predict its increasing use in quotidian practice.
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November 2016

Caudal Duplication Syndrome: the Vital Role of a Multidisciplinary Approach and Staged Correction.

European J Pediatr Surg Rep 2016 Dec 31;4(1):1-5. Epub 2015 Dec 31.

Department of Pediatric Surgery, Schneider Children's Medical Center, Sackler Medical School, University of Tel Aviv, Petach Tikvah, Israel.

Caudal duplication syndrome is a rare entity that describes the association between congenital anomalies involving caudal structures and may have a wide spectrum of clinical manifestations. A full-term male presented with combination of anomalies including anorectal malformation, duplication of the colon and lower urinary tract, split of the lower spine, and lipomyelomeningocele with tethering of the cord. We report this exceptional case of caudal duplication syndrome with special emphasis on surgical strategy and approach combining all disciplines involved. The purpose of this report is to present the pathology, assessment, and management strategy of this complex case.
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http://dx.doi.org/10.1055/s-0035-1570370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177553PMC
December 2016

The Effect of Elevated Intra-Abdominal Pressure on TLR4 Signaling in Intestinal Mucosa and on Intestinal Bacterial Translocation in a Rat.

J Laparoendosc Adv Surg Tech A 2017 Feb 22;27(2):211-216. Epub 2016 Nov 22.

1 The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology , Laboratory of Intestinal Adaptation and Recovery, Haifa, Israel .

Background: Recent evidence suggests that elevated intra-abdominal pressure (IAP) may adversely affect the intestinal barrier function. Toll-like receptor 4 (TLR-4) is responsible for the recognition of bacterial endotoxin or lipopolysaccharide and for initiation of the Gram-negative septic shock syndrome. The objective of the current study was to determine the effects of elevated IAP on intestinal bacterial translocation (BT) and TLR-4 signaling in intestinal mucosa in a rat model.

Methods: Male Sprague-Dawley rats were randomly assigned to one of two experimental groups: sham animals (Sham) and IAP animals who were subjected to a 15 mmHg pressure pneumoperitoneum for 30 minutes. Rats were sacrificed 24 hours later. BT to mesenteric lymph nodes, liver, portal vein blood, and peripheral blood was determined at sacrifice. TLR4-related gene and protein expression (TLR-4; myeloid differentiation factor 88 [Myd88] and TNF-α receptor-associated factor 6 [TRAF6]) expression were determined using real-time PCR, western blotting, and immunohistochemistry.

Results: Thirty percent of sham rats developed BT in the mesenteric lymph nodes (level I) and 20% of control rats developed BT in the liver and portal vein (level II). abdominal compartment syndrome (ACS) rats demonstrated an 80% BT in the lymph nodes (Level I) and 40% BT in the liver and portal vein (Level II). Elevated BT was accompanied by a significant increase in TLR-4 immunostaining in jejunum (51%) and ileum (35.9%), and in a number of TRAF6-positive cells in jejunum (2.1%) and ileum (24.01%) compared to control animals. ACS rats demonstrated a significant increase in TLR4 and MYD88 protein levels compared to control animals.

Conclusions: Twenty-four hours after the induction of elevated IAP in a rat model, increased BT rates were associated with increased TLR4 signaling in intestinal mucosa.
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http://dx.doi.org/10.1089/lap.2016.0212DOI Listing
February 2017

A pilot study examining the relationship among Crohn disease activity, glucagon-like peptide-2 signalling and intestinal function in pediatric patients.

Can J Gastroenterol 2013 Oct;27(10):587-92

Unlabelled: BACKGROUND⁄

Objectives: The relationship between the enteroendocrine hormone glucagon-like peptide 2 (GLP-2) and intestinal inflammation is unclear. GLP-2 promotes mucosal growth, decreases permeability and reduces inflammation in the intestine; physiological stimulation of GLP-2 release is triggered by nutrient contact. The authors hypothesized that ileal Crohn disease (CD) affects GLP-2 release.

Methods: With ethics board approval, pediatric patients hospitalized with CD were studied; controls were recruited from local schools. Inclusion criteria were endoscopy-confirmed CD (primarily of the small intestine) with a disease activity index >150. Fasting and postprandial GLP-2 levels and quantitative urinary recovery of orally administered 3-O-methyl-glucose (active transport) and lactulose⁄mannitol (passive) were quantified during the acute and remission phases.

Results: Seven patients (mean [± SD] age 15.3 ± 1.3 years) and 10 controls (10.3 ± 1.6 years) were studied. In patients with active disease, fasting levels of GLP-2 remained stable but postprandial levels were reduced. Patients with active disease exhibited reduced glucose absorption and increased lactulose⁄mannitol recovery; all normalized with disease remission. The change in the lactulose⁄mannitol ratio was due to both reduced lactulose and increased mannitol absorption.

Conclusions: These findings suggest that pediatric patients with acute ileal CD have decreased postprandial GLP-2 release, reduced glucose absorption and increased intestinal permeability. Healing of CD resulted in normalization of postprandial GLP-2 release and mucosal functioning (nutrient absorption and permeability), the latter due to an increase in mucosal surface area. These findings have implications for the use of GLP-2 and feeding strategies as a therapy in CD patients; further studies of the effects of inflammation and the GLP-2 axis are recommended.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805340PMC
http://dx.doi.org/10.1155/2013/460958DOI Listing
October 2013

Thoracoscopic segmentectomy for congenital and acquired pulmonary disease: a case for lung-sparing surgery.

J Laparoendosc Adv Surg Tech A 2014 Jan 28;24(1):50-4. Epub 2013 Sep 28.

1 The Rocky Mountain Hospital for Children , Denver, Colorado.

Purpose: Over the last 15 years thoracoscopic lobectomy for congenital and acquired lesions has become an accepted modality in pediatric thoracic surgery. There is still debate about the need to perform a complete lobectomy for some of these lesions, and some advocate observation rather than resection, despite possible long-term complications of untreated lesions. High-resolution computed tomography (CT) scans and physical findings at the time of surgery, along with new advanced techniques, now allow for discrete partial anatomic resections, which may preserve normal lung. This study evaluates the feasibility and early results using these techniques in selected cases.

Patients And Methods: With institutional review board approval, the records of all patients undergoing thoracoscopic lung resection were reviewed. From January 2006 to December 2012, 23 patients, ranging from 1 month to 16 years of age and weighing 3.8-42 kg, underwent thoracoscopy for planned resection. Pathology was congenital cystic lung disease in 19 patients, bronchiectasis in 3 patients, and arteriovenous malformation in 1 patient. In each case findings on CT scan and at the time of surgery warranted consideration of lung-preserving surgery. Procedures were performed through three ports using single lung ventilation and CO2 insufflation to achieve lung collapse. The LigaSure™ device (Covidien, Norwalk, CT) was the primary instrument used to seal and divide the lung parenchyma and seal vessels.

Results: All procedures were completed successfully thoracoscopically. An anatomic segmental resection was achieved in 22 of 23 cases. Operative time ranged from 30 to 300 minutes (mean, 120 minutes). Segmental resections included the left upper lobe apical/posterior (n=4), lingula (n=3), left lower lobe superior (n=5), medial or posterior basal (n=3), right middle lobe medial (n=1), right upper lobe apical (n=1), right lower lobe superior (n=4), and posterior basal (n=2). Two patients had more than one segment excised. Chest tubes were left in for 24 hours in 16 cases, 48 hours in 4 cases, and 5 days in 1 case. Hospital stay ranged from 1 to 6 days (mean, 2 days). Follow-up CT scans obtained at 1-6 years (mean, 28 months) show no residual disease in 20 of 21 patients. One patient underwent a nonanatomic resection and had evidence of recurrent congenital pulmonary airway malformation at the 4-year follow-up. This patient underwent a secondary thoracoscopic resection.

Conclusions: Thoracoscopic lung-conserving therapy is technically feasible and safe in infants and children. The magnification provided by a thoracoscopic approach makes identification of segmental anatomic planes easier, aiding in safe dissection and resection. Anatomic resection appears to be associated with a low morbidity. It may be appropriate in the case of bilateral or extensive disease or in cases where the diseased tissue is clearly limited to an anatomic segment. Continued long-term follow-up is needed.
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http://dx.doi.org/10.1089/lap.2013.0337DOI Listing
January 2014

[Minimal invasive surgical correction of pectus excavatum deformities in adolescents: our institutional experience].

Srp Arh Celok Lek 2013 Jul-Aug;141(7-8):503-6

Clinic for Pediatric Surgery, Institute for Health Care of Children and Youth of Vojvodina, Novi Sad, Serbia.

Introduction: Nuss procedure is a minimal invasive surgical technique based on retrosternal placement of a metal plate to correct pectus excavatum chest deformity. We are presenting our five-year (2006-2011) institutional experience of 21 patients.

Objective: The aim of this study was to determine characteristics and advantages of minimal invasive surgical approach in correcting deformities of the chest.

Methods: Surgical procedure, named after its author Nuss, involves the surgical placement of a molded metal plate, the so-called pectus bar, behind the sternum under thoracoscopic view whereby immediate controlled intraoperative corrections and stabilizations of the depression can be made.The great advantage of this method is reflected in a significant shortening of operative time, usually without indications for compensation in blood volume, and with a significantly shortened postoperative recovery that allows patients to quickly return to their normal activities.

Results: In the period 2006-2011, 21 patients were operated by the Nuss procedure. The pectus bar was set in front or behind the muscles of the chest. Among the complications listed were inflammation of wounds in three patients, dislocation (shifting) of the bar requiring a reoperation in two patients, an occurrence of a pericardial effusion in one patient, and allergic response to foreign body in one patient. Five patients required extraction of the bar two years later, and three patients after three years, all with excellent results.

Conclusion: Minimally invasive Nuss procedure is safe and effective. It currently represents the primary method of choice for solving the chest deformity pectus excavatum for patients of all ages. Modification of thoracoscopic control allows a safe field of operation. Postoperative results are excellent with very few complications that can be attributed to the learning curve.
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November 2015

Perineal hernias in children: case report and review of the literature.

Afr J Paediatr Surg 2012 May-Aug;9(2):172-5

Department of Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Perineal hernias (pelvic floor hernias) are extremely rare occurring through defects in musculature of the pelvic floor. This report presents a successfully treated case of primary perineal hernia and takes a review of the existing literature. The case of a 14-month-old girl with a great perineal hernia is presented. Diagnosis was secured by barium enema. The pelvic defect was successfully treated by primary suture with prolene. The literature shows many different approaches for treatment of perineal hernia, such as open or laparoscopic mesh repair, and perineal, abdominal or combined access in the adult, but our case like others confirms that primary closure of the hernial orifice through a perineal approach is also feasible in children.
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http://dx.doi.org/10.4103/0189-6725.99411DOI Listing
January 2013

Thoracoscopic sympathectomy ganglia ablation in the management of palmer hyperhidrosis: a decade experience in a single institution.

Afr J Paediatr Surg 2012 May-Aug;9(2):143-7

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Rabin Measical Center, Petach Tikva, Israel.

Background: Hyperhidrosis can cause significant professional and social handicaps. Surgery is the preferred treatment modality for hyperhidrosis. There has been evolution in the surgical management of hyperhidrosis. This study evaluated the place of minimally invasive surgical approach and its long-term outcome in the management of hyperhidrosis.

Patients And Methods: A 10-year prospective study of all children and adolescents who underwent thorascopic sympathectomy at the Schneider Children's Hospital of Israel. Data were validated for the procedure and analysed for outcome of procedure.

Results: There were 148 patients, 66 were males and 82 were females, with a median age of 13.8 SD ± 4.0 years. Two hundred and ninety-six thoracopic sympathectomies were performed with no conversion to open procedure. The mean operation time was 18 min. Ninety-five per cent of the patients were discharged the next day with a mean hospital stay of 1.2 days. Postoperative complications included segmental atelectasis in seven (4.72%) patients, pneumothorax in two (1.35%) and transient unilateral Horner's syndrome in one (0.67%). Seventy-one (38.8%) experienced some form of compensatory hyperhidrosis. Complete relief of palmer hyperdidrosis was achieved in all patients (mean follow-up = 5.03 ± 1.76 years). The outcome was very satisfactory in 91 (61.5%) and satisfactory in 48 (32.4%). Only nine (6.1%) were not satisfied with the outcome.

Conclusion: Thorascopic sympathectomy provides effective and satisfactory cure for palmer hyperhidrosis with acceptable complication rate and excellent satisfactory outcome. There is a possibility of compensatory sweating in some individuals.
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http://dx.doi.org/10.4103/0189-6725.99402DOI Listing
January 2013

Androgen insensitivity syndrome: risk of malignancy and timing of surgery in a paediatric and adolescent population.

Afr J Paediatr Surg 2011 May-Aug;8(2):194-8

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Sackler Medical School, University of Tel Aviv, Israel.

Background: Management of female phenotype XY disorders poses a series of problems for the treating clinician. Even after a series of investigations and imaging modalities, there are lingering doubts about the exact nature of the disease and the correct management option. Optimal timing and necessity for removal of their testes have been a debated issue by physicians. There is a generally accepted opinion among physicians that the risk of malignancy in androgen insensitivity syndrome (AIS) is considerably lower than with other intersex disorders and occurs at a later age.

Objective: The highlight of this presentation is to reinforce the value of laparoscopic gonadectomy in management of AIS in correlation with data suggesting higher risk of malignancy.

Patients And Methods: A retrospective review of 11 phenotypic females with XY karyotype was carried out. The patients were evaluated by a diagnostic protocol which included clinical, hormonal, sonographic and cytogenetic examinations. Patients/parents were counselled by the team concerning the different treatment modalities and contrary to the assigned gender, laparoscopy was offered to them. Uneventful bilateral gonadectomy was performed in all the patients and gonads submitted for histopathological examination.

Results: A total of 11 patients (mean age, 10.4 ± 4.1 years), including six with complete AIS and five with partial AIS (PAIS) were reviewed. In two patients with PAIS (18.1%), histopathology revealed malignancy (bilateral seminoma and gonadoblastoma) and in an additional patient, a benign hamartoma was found. Literature evidence suggests that AIS female phenotype patients retaining their testes through puberty have a 5% chance for developing malignant tumours. Reviewing our results in correlation with literature, we found that PAIS patients may harbour a higher risk of malignancy.

Conclusions: In complementation to hormonal tests and cytogenetic techniques, laparoscopic gonadectomy is required to complete the diagnostic work up for AIS as it also adds a final therapeutic approach with low risk and huge benefit. Since laparoscopy is now a well-tolerated and widely accepted gold standard, it should be included in routine management for patients with AIS. Risk of malignancy in PAIS should be investigated in larger cohort of these patients.
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http://dx.doi.org/10.4103/0189-6725.86061DOI Listing
February 2012

Growth differentiating factor 9 (GDF9) and bone morphogenetic protein 15 both activate development of human primordial follicles in vitro, with seemingly more beneficial effects of GDF9.

J Clin Endocrinol Metab 2011 Aug 1;96(8):E1246-54. Epub 2011 Jun 1.

Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, Petach Tikva 49100, Israel.

Context: The signals initiating growth of primordial follicles are unknown. Bone morphogenetic protein 15 (BMP15) and growth differentiating factor 9 (GDF9) are promising candidates.

Objective: The objective of the study was to evaluate for the first time the effects of human recombinant BMP15 and human recombinant GDF9 on the in vitro development of human primordial follicles.

Design And Setting: This was a controlled culture study performed in a major tertiary university-affiliated medical center.

Materials: Materials included ovarian tissue from 17 girls/women and three aborted human fetuses.

Intervention: There were no interventions.

Main Outcome Measure: Histological and immunohistochemical (proliferating cell nuclear antigen, BMP15, and GDF9) studies and an endocrine assay of 17β-estradiol were conducted.

Results: In the samples from girls/women, the number of developing follicles was greater with GDF9 or BMP15 alone than with no BMP15 or GDF9. Higher 17β-estradiol secretion was noted after treatment with GDF9 than with BMP15 or with GDF9+anti-GDF9. The number of atretic follicles was greater with BMP15 than with GDF9. Proliferating cell nuclear antigen expression was greater with the higher dose of both growth factors than the lower dose. Expression of BMP15 and GDF9 was identified in samples cultured without BMP15 or GDF9. Results for the fetal follicles yielded no distinguishable pattern.

Conclusions: Although both BMP15 and GDF9 promoted activation of human primordial follicles from girls/women (but not human fetuses) in a dose-dependent manner, GDF9 seems more beneficial.
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http://dx.doi.org/10.1210/jc.2011-0410DOI Listing
August 2011

Laparoscopic-assisted retrieval of migrated intra-abdominal pacemaker generator.

Pediatr Cardiol 2011 Dec 12;32(8):1196-8. Epub 2011 Apr 12.

Pediatric Surgery Department, Schneider Children's Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 49202, Petah Tikva, Israel.

A 5-year-old boy born with a congenital heart defect had insertion of an epicardial pacemaker that was found on routine evaluation to have been displaced into the rectovesical pouch. He underwent transvenous insertion of another pacemaker, and the displaced pacemaker was successfully retrieved by laparoscopy without incident.
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http://dx.doi.org/10.1007/s00246-011-9972-1DOI Listing
December 2011

WITHDRAWN: Bone Morphogenetic Protein 15 (BMP15)/Growth Differentiating Factor 9 Heterodimer Is More Potent than BMP15 Alone in in Vitro Activation of Human Primordial Follicles.

J Clin Endocrinol Metab 2011 Feb 16. Epub 2011 Feb 16.

Infertility and IVF Unit (A.K., B.F., R.G., A.B.-Z., T.G., C.F., A.B.-H., R.A.), Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, Petach Tikva 49100, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978 Israel, and Department of Pediatric Surgery (D.K.), Schneider Children's Medical Center of Israel, Rabin Medical Center, Petach Tikvah, 49202 Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.

This manuscript was withdrawn at the request of the authors.
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http://dx.doi.org/10.1210/jc.2010-1749DOI Listing
February 2011

The 16 golden hours for conservative treatment in children with postoperative small bowel obstruction.

J Pediatr Surg 2010 May;45(5):966-8

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petach Tikva 49 202, Israel.

Background: Conservative treatment of postoperative small bowel obstruction in children is widely accepted, provided that there are no clinical signs of bowel strangulation. However, the length of time surgery can be safely deferred remains unclear.

Purpose: The aim of this study was to determine the time limit for observant management of postoperative small bowel obstruction.

Methods: The medical records of 128 children with 174 episodes of postoperative small bowel obstruction were reviewed.

Results: Spontaneous resolution occurred in 63% of cases, 85% within 48 hours of admission. Bowel compromise was noted in 31% of the operated cases, and about half of them underwent bowel resection, accounting for 6% of all admissions. None of the cases treated surgically within 16 hours of admission was associated with bowel strangulation or need for resection.

Conclusions: In children presenting with postoperative small bowel obstruction, prolonging observant treatment for more than 48 hours yields only a small benefit in terms of spontaneous resolution. Bowel strangulation can occur within 16 hours of admission. On the basis of these findings, we suggest raising the index of suspicion for compromised bowel after 16 hours and making the decision for surgery at around 48 hours.
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http://dx.doi.org/10.1016/j.jpedsurg.2010.02.025DOI Listing
May 2010

The impact of laparoscopy in the management of non-palpable testes.

Pediatr Endocrinol Rev 2009 Sep;7(1):44-7

Department of Pediatric and Adolescent Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Undescended testis is one of the most common congenital abnormalities of the genitourinary system. In 10-20% of these boys, a testis is located completely inside the abdominal cavity. Multiple operative techniques have been described and are associated with a variable success rate. In this review we evaluate the use of laparoscopy in the management of the non-palpable testis to determine what advantages it might offer over the open technique. On the basis of current evidence it seems that laparoscopy is the only diagnostic and therapeutic procedure that is accurate enough to elucidate the diagnosis of non-palpable testis and also allows surgical treatment to be carried out in the same setting.
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September 2009

Nutritional effects of the serial transverse enteroplasty procedure in experimental short bowel syndrome.

J Pediatr Surg 2009 Aug;44(8):1552-9

Alberta Children's Hospital, Department of Surgery and Gastrointestinal Research Group, Institution of Infection Immunity and Inflammation, Faculty of Medicine, University of Calgary, Health Science Center, Calgary, Alberta, Canada.

Background/purpose: The serial transverse enteroplasty (STEP) procedure appears beneficial clinically, but the mechanism(s) underlying these effects remains unclear. The present study evaluated the nutritional, hormonal, and morphologic effects of the STEP procedure in a rodent model of short bowel syndrome.

Methods: With institutional animal care ethics approval, Sprague-Dawley rats underwent an 80% distal bowel resection, anastomosing the 30 cm remnant of jejunum to the ascending colon; at day 14, animals were randomly assigned to control or a STEP procedure (n = 8/group). Animals were pair-fed with normal chow; after a further 3 weeks, intestinal transit, hormonal and metabolic balance studies were done, and intestinal tissues were taken for analysis.

Results: The STEP group had increased weight gain (resected: -0.34% +/- 2.9% vs STEP: 2.5% +/- 1.5%), increased bowel length (34.1 +/- 1.5 vs 36.9 +/- 2.2 cm), increased jejunal villus height (555 +/- 59 vs 635 +/- 65 microm), decreased rates of crypt cell apoptosis, increased expression of mRNA for the GLP-2 receptor, and increased postprandial production of glucagon-like peptide 2 (45 +/- 14 vs 65 +/- 12 pmol/L) (P < .05 by Student t test). There were no differences in intestinal transit; absorption of total calories, protein, fat, or carbohydrate; crypt cell proliferation rates; or the expression of intestinal transporter proteins (SGLT-1, GLUT-2, and GLUT-5).

Conclusions: The STEP procedure improves weight gain and augments gross and microscopic intestinal morphology in severe experimental short bowel syndrome. Postprandial GLP-2 levels are increased, as is the expression of the GLP-2 receptor; these mechanisms may contribute to these metabolic effects and may be useful in guiding the use of the STEP procedure clinically.
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http://dx.doi.org/10.1016/j.jpedsurg.2008.10.001DOI Listing
August 2009

Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality.

Pediatr Surg Int 2009 Jul 11;25(7):583-6. Epub 2009 Jun 11.

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petah Tiqwa 49202, Israel.

Background: Previous analyses of the safety of the conservative versus the operative approach to the treatment of liver and spleen blunt injuries in children often failed to account for differences in quality of care and expertise among dedicated pediatric trauma center, non-pediatric centers, centers without trauma units, and non-trauma centers. To eliminate this potential bias, the present study examined changes in the rate of surgery and their impact on outcome within the same medical centers over time.

Methods: The Israel Trauma Registry was searched for patients <18 years who were treated for non-penetrating liver or spleen injuries from 1998 to 2004. Patients were grouped by period, 1998-2000 and 2001-2004, and compared for type of injury, severity of injury, type of treatment, and inpatient mortality.

Results: The earlier period (1998-2000) was characterized by a significantly higher rate of operations compared with the later period (2001-2004) (P = 0.001) and higher in-hospital mortality (P = 0.04). Injury severity scores, type of organs injured, and accompanying injuries were similarly distributed in the two groups.

Conclusions: Despite the similarity in the severity and characteristics of the intraabdominal injuries in 1998-2000 and in 2001-2004, the proportion of children treated conservatively increased over time, concomitant with a significant drop in inpatient mortality. We attribute this shift over a relatively short interval to increased experience and greater acceptance of conservative management in this setting.
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http://dx.doi.org/10.1007/s00383-009-2398-7DOI Listing
July 2009

Operative innovation to the "Nuss" procedure for pectus excavatum: operative and functional effects.

J Pediatr Surg 2009 May;44(5):888-92

Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.

Background: The "Nuss" procedure for repair of pectus excavatum is performed with increasing frequency worldwide. We describe a technique of performing relaxing or "kerf" incisions along the cartilaginous ribs at the point of maximal chest wall concavity to facilitate retrosternal dissection and to reduce chest wall tension. The effects on operative parameters and long-term changes in cardiopulmonary function and appearance were evaluated prospectively.

Methods: Thirty patients underwent a Nuss procedure for the period from 2001 to 2004. Fifteen patients underwent a modified Nuss (MN) with sternocostal "relaxing" incisions, and these were compared to 15 patients undergoing a standard Nuss (SN). Data were prospectively gathered and included the number of relaxing incisions, bar number, blood loss, duration of epidural analgesia, number of days to discharge, and preoperative and postoperative cardiopulmonary function measures.

Results: The average Haller index of the SN group was 3.9 +/- 0.7 vs MN group index of 4.6 +/- 1.6 (P < .05). The median number of relaxing incisions in the study group was 4.0 +/- 0.7 (range 3 - 8). There were no significant differences between the study groups in any of the operative parameters analyzed, including blood loss, days of epidural requirements or days to reach functional independence. Nor were there differences in the improvement in subjective appearance, complications, pulmonary function, cardiac output at rest, oxygen transport or minute ventilation at maximal exercise. Subjectively, bar positioning and the intraoperative visualization was easier with the relaxing incisions.

Conclusions: The addition of sternocostal relaxing incisions to the standard Nuss procedure appears to facilitate retrosternal dissection and bar placement, but no changes in long-term function or cosmesis were noted. The use of relaxing incisions appears to be safe and may facilitate operative visualization of retrosternal structures.
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http://dx.doi.org/10.1016/j.jpedsurg.2009.01.020DOI Listing
May 2009

Impact of cecostomy and antegrade colonic enemas on management of fecal incontinence and constipation: ten years of experience in pediatric population.

J Pediatr Surg 2008 Aug;43(8):1445-51

Pediatric Surgery Department, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.

Background: In childhood and adolescence, fecal soiling represents a psychologically devastating problem. Physical and emotional distress associated with daily rectal enemas is minimized by the introduction of a cecostomy tube for colonic cleansing with antegrade colonic enemas (ACEs).

Patients And Methods: Over a period of 10 years (1997-2007), we performed "button" cecostomies in 69 pediatric patients with fecal soiling secondary to a variety of disorders; laparoscopic procedures were performed in 40 and open procedures in 29. Mean postoperative follow-up was 4.03 SD +/- 1.76 years. Cleansing protocols differed between patients.

Results: We adopted a standardized questionnaire concerning management of incontinence/intractable constipation before and after button cecostomy insertion to assess the long-term impact of ACE on symptom severity and quality of life. Complications included tube dislodgement (n = 9), development of granulation tissue (n = 11), decubitus ulcer (n = 5), and infection (n = 3). Patient/parents satisfaction (appraisal scale 1-3) and improvement of quality of life achieved statistical significance for both (P < .001).

Conclusions: Since button cecostomy and ACE were introduced in our institution as a management option, the treatment of fecal incontinence and intractable constipation significantly improved in terms of efficacy and patient compliance and also resulted in greater patient and parent satisfaction.
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http://dx.doi.org/10.1016/j.jpedsurg.2007.12.051DOI Listing
August 2008

Laparoscopic resection of extra-adrenal pheochromocytoma--case report and review of the literature in pediatric patients.

J Pediatr Surg 2007 Oct;42(10):1780-4

Department of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Canada T3B 6A8.

Surgery for pheochromocytoma differs from that of other tumors owing to the potential release of catecholamines, which may lead to severe intraoperative hemodynamic changes. The present standard of care for resection of adrenal pheochromocytoma has become a laparoscopic approach for surgical excision. Extra-adrenal pheochromocytoma is a very rare entity, especially in the pediatric age group; the utility of the laparoscopic approach is not established in this population. We present a case report of a child with hormonally active extra-adrenal pheochromocytoma originating in the organ of Zuckerkandl that was resected laparoscopically. We found the laparoscopic approach gave excellent exposure, allowing for proper identification of the tumor's origin and its relation to surrounding structures; a complete resection with excellent control of the feeding blood vessels was performed. Herein we present the details of this case and a review of the relevant literature. After our initial experience we can recommend laparoscopic exploration for similar cases of suspected extra-adrenal pheochromocytoma as an appropriate tool to identify extension of the disease and estimate resectability. Proper patient preparation and monitoring are critical for success.
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http://dx.doi.org/10.1016/j.jpedsurg.2007.06.025DOI Listing
October 2007

Clinical impact of optical imaging with 3-D reconstruction of torso topography in common anterior chest wall anomalies.

J Pediatr Surg 2007 May;42(5):898-903

Department of Mechanical and Manufacturing Engineering, University of Calgary, Calgary, AB, Canada T2N 1N4.

Background: Standard modalities to assist in determining the extent of chest wall developmental deformities in patients include x-ray and computed tomography (CT). The purpose of this study is to describe an optical imaging technique that provides accurate cross-sectional images of the chest, and to compare these with standard CT-derived images of chest wall abnormalities.

Patients And Methods: Ten patients (5 pectus excavatum and 5 pectus carinatum) underwent imaging that included limited CT and optical cross-sectional imaging. Severity indices of the deformity using the standard Haller index (HI) were calculated from CT scans. A similar severity measurement of deformity was derived from the outline of torso cross sections (ie, from skin to skin measurements) obtained from optical images. To assess the severity of carinatum defects, a modified pectus index was derived, which measures the anterior chest protrusion from the central chord of the chest cross section. We performed regression analyses, comparing the indices obtained from CT and optical imaging methodologies.

Results: Optical measures of cross-sectional deformities correlated well with standard HI (r2 = 0.94) and even better with the modified pectus index (r2 = 0.96). Adaptation of the HI for pectus carinatum deformity evaluation was effective, and consistent with the torso surface deformity measures.

Conclusions: Torso models from optical imaging offer 3-D images of the chest wall deformity with no radiation exposure. This preliminary study showed promising results for the use of torso surface measurement as an alternative index of pectus deformities; if validated in larger studies, these measures may be useful for following chest wall abnormalities, using repeated studies in patients.
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http://dx.doi.org/10.1016/j.jpedsurg.2006.12.070DOI Listing
May 2007

Laparoscopic ovarian tissue preservation in young patients at risk for ovarian failure as a result of chemotherapy/irradiation for primary malignancy.

J Pediatr Surg 2007 May;42(5):862-4

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Aggressive chemotherapy/radiotherapy for cancer may cause gonadal failure in young female survivors. The putative aim of ovarian tissue cryopreservation is to restore fertility by transplantation of a patient's frozen-thawed ovarian tissue or, further into the future, by in vitro maturation of frozen-thawed oocytes followed by in vitro fertilization. This report presents our early experience with ovarian tissue preservation in young patients.

Methods: We conducted a database review of the techniques and outcomes of the ethics board-approved ovarian tissue cryopreservation procedures performed at our center since 1998 for young girls with malignancy.

Results: The study group included 23 patients (median age = 14 years) with various types of cancer (hematologic, bone, ovarian, or intracranial); 11 patients were scheduled for chemotherapy, 11 patients had already undergone some form of chemotherapy before the ovarian tissue harvesting, and 1 patient was not scheduled for chemotherapy. Ten underwent bone marrow transplantation after tissue retrieval. Twenty-one patients underwent laparoscopic harvesting of their ovarian tissue. In the other 2 patients, the ovary was preserved during inguinal hernia repair or tissue was obtained at laparotomy for a pelvic tumor. All patients had benign operative and postoperative courses.

Conclusions: Laparoscopy for ovarian tissue retrieval for cryopreservation is safe in young cancer patients. Based on reports of successful cryopreservation of human ovarian tissue containing primordial follicles, we believe that this approach holds promise for female cancer survivors.
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http://dx.doi.org/10.1016/j.jpedsurg.2006.12.041DOI Listing
May 2007

Colorectal carcinoma in childhood: a retrospective multicenter study.

J Pediatr Gastroenterol Nutr 2007 Feb;44(2):209-11

Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.

Objectives: Colorectal carcinoma, a common adult malignancy, has an estimated childhood incidence of 0.3 to 1.5/million in Western countries and 0.2/million in Israel. Diagnosis is difficult because adult screening measures are unfeasible in children. The tumor is frequently associated with predisposing genetic factors, aggressive biological behavior, and poor prognosis. The aim of this multicenter study was to document the clinical profile, treatment and prognosis of colorectal carcinoma in children in Israel.

Patients And Methods: The clinical, laboratory, therapeutic, and prognostic parameters of all 7 children from 4 medical centers in Israel who were diagnosed with colorectal carcinoma over a 25-y period were reviewed.

Results: Patients presented with rectal bleeding (4 of 7), abdominal pain (2 of 7), and abdominal distension (2 of 7). Average time to diagnosis was 6 months. Six patients underwent surgery (1 refused), and 5 received chemotherapy. Histopathological studies showed poorly differentiated mucinous adenocarcinoma, signet-ring type, in 4 cases, moderately differentiated adenocarcinoma in 2, and well-differentiated carcinoma in 1. Three patients died of the disease, 2 shortly after diagnosis. One patient with recurrent metastatic disease was lost to follow-up.

Conclusion: Colorectal carcinoma in children is characterized by aggressive tumor behavior and delayed diagnosis, resulting in a worse prognosis than in adults. Heightened physician awareness of the possibility of this disease in children, with special attention to adolescents with predisposing factors and rectal bleeding, could help to improve outcome.
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http://dx.doi.org/10.1097/01.mpg.0000252195.84084.52DOI Listing
February 2007

Long term cardiopulmonary effects of closed repair of pectus excavatum.

Pediatr Surg Int 2007 May;23(5):493-7

Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, Canada.

The closed or "Nuss" repair of pectus excavatum is widely accepted for correction of moderate to severe deformities. Patients typically report significant subjective improvements in pulmonary symptoms, and short and medium term evaluations (up to 2 years with the bar in place) suggest modest improvement to cardiac function but a decrease in pulmonary function. This study examined the effects at 3 months post-bar removal of closed repair of pectus on pulmonary function, exercise tolerance and cardiac function. Patients were followed prospectively after initial evaluation for operation. All patients underwent preoperative and post-bar removal evaluation with CT scan, complete pulmonary function and exercise testing to anaerobic threshold, as well as echocardiogram. Twenty-six patients have completed the follow up protocol. Preoperative CT index was 4.5 +/- 1.3, average age at operation was 13.2 years, and average tanner stage was 3.5 +/- 0.5. At 3 months or greater follow-up post-bar removal, patients reported an improvement in subjective ability to exercise and appearance (P < 0.05 by wilcoxin matched pairs). Objective measures of FEV1, total lung capacity, diffusing lung capacity, O(2) pulse, VO(2max), and respiratory quotient all showed significant improvement compared to preoperative values, while normalized values of cardiac index at rest did not (All values normalized for height and age, comparisons P < 0.05 by student's paired t test). These results demonstrate a sustained improvement in cardiopulmonary function after bar removal following closed repair of pectus excavatum. These findings contrast with results from previous studies following the open procedure, or with the closed procedure at earlier time points; the long term physiological effects of closed repair of pectus excavatum include improved aerobic capacity, likely through a combination of pulmonary and cardiac effects.
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http://dx.doi.org/10.1007/s00383-006-1861-yDOI Listing
May 2007

Teaching impact in pediatric minimal access surgery: Personal perspective from "Fellow".

J Minim Access Surg 2006 Dec;2(4):216-9

Alberta Children's Hospital, Calgary, Alberta, Canada.

The global objective of this paper is to review from the "Fellow" perspective, the current status of pediatric minimal access surgery (MAS) in terms of teaching feasibility, safety and impact on standard practice paradigms. In the pediatric general surgery field, surgeons are dealing with a wide range of pathology that includes thoracic, abdominal, urological and gynecological procedures. The learning curve is slow because of a relatively small volume of patients. However, gradually but steadily, a significant proportion of the procedures traditionally performed, with major open exposures at present, are preferentially performed by minimal access. Currently, minimal access surgery training is incorporated into adult general surgery residency/fellowship programs and teaching techniques of pediatric MAS are available only as seldom international workshops. Pediatric surgery fellowship programs with incorporated guidelines for MAS training are just recently feasible in select centers, mostly as "self" established programs. In many other pediatric surgery centers, teaching the "glamour" of MAS is quite dependent on a program director's vision. Integration of MAS training into the secondary residency/fellowship curriculum of pediatric surgeons is the inevitable goal. MAS- minded education and research through adequate training will pay dividends and "manufacture" competent, contemporary trainees. National Pediatric Surgery Associations should be responsible for setting criteria that consider the MAS for accreditation with maintaining the international standards of these teaching programs.
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http://dx.doi.org/10.4103/0972-9941.28183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016483PMC
December 2006