Transcript Advances in Pediatric MIS Over The Past Decade

Advances in Pediatric MIS
Over The Past Decade
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri
Advances in MIS
1.
Development of Surgical Technique



2.
Thoracoscopic lobectomy
Thoracoscopic repair EA/TEF
Single site umbilical laparoscopic surgery (SSULS)
Refinement in Surgical Technique


Laparoscopic fundoplication
Laparoscopic pyloromyotomy
3.
Definition of Perforated Appendicitis
4.
Evidence Based Studies in MIS
5.
Consensus B/W Drs. Pena & Georgeson regarding
laparoscopy for anorectal atresia with a fistula above the
prostatic urethra (IPEG 2009)
Advances in MIS
6. Growth of IPEG
7. Development of good 3 mm instruments
8. Development of HD picture
9. Development of the stab incision
technique
Development of A Surgical Technique
Thoracoscopic Repair EA/TEF –
Lessons Learned
• Baby should ideally be >2.5 kg
• Bronchoscopy to identify fistula to
gauge distance
• Oscillating ventilator helpful
• Is metal clip good for ligating
TEF?
• When to convert?
• How to train staff and residents?
Thoracoscopic Repair EA/TEF
Development of A Surgical Technique
Thoracoscopic Repair EA/TEF –
Lessons Learned
Oscillating Ventilator Helpful
Development of A Surgical Technique
Thoracoscopic Repair EA/TEF –
Lessons Learned
Is the metal clip appropriate
for ligating the TEF?
Can a recurrent TEF be
prevented?
J Laparoendosc Adv Surg Tech 17:380-382, 2007
Development of A Surgical Technique
Thoracoscopic Repair EA/TEF –
Lessons Learned
• When to convert?

After ligation & division of TEF - if the gap
is too large (2 -3 cm)?
• How do we train staff and residents?
Thoracoscopic Repair EA/TEF
Results
(104 Patients)
Mean Age (days)
1.2 (± 1.1)
Mean Wt (kg)
2.6 (± 0.5)
Mean Operative Time (min)
Mean Days Ventilation
Mean Hospitalization (days)
129.9 (± 55.5)
3.6 (± 5.8)
18.1 (± 18.6)
Thoracoscopic Repair EA/TEF
(104 Patients)
• Fistula Ligation
 37 pts: suture ligation
 67 pts: clip ligation
Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEF
Associated Anomalies
(104 Patients)
Cardiac
ASD/VSD
Right aortic arch
Tetralogy of Fallot
Dextrocardia
PDA (ligation)
DORV
Tricuspid atresia
Gastrointestinal
High imperforate anus
Duodenal atresia
Low imperforate anus
Cloaca
Syndromes
VACTERL (>2 anomalies)
CHARGE
Down
15
6
3
3
2
1
1
7
4
3
1
10
3
3
Renal
Horseshoe kidney
Unilateral agenesis
Crossed fused ectopia
VUR > Grade 3
Duplex kidney
Ectopic kidney
3
2
1
1
1
1
Other
Vertebral anomalies
Radial aplasia
Tethered cord
Hydromyelia
Choanal atresia
6
3
1
1
1
Thoracoscopic Repair EA/TEF
Results
(104 Patients)
• Fundoplication
26
(22 Nissen, 4 Thal)
• Aortopexy
7
( 6 thoracoscopic)
• Duodenal atresia
4
(4 laparoscopic)
• Imperforate anus
10
(7 high, 3 low)
• Cardiac operations
5
( other than VSD/ASD)
Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEF
Complications
(104 Patients)
• Recurrent fistula
2
( 3 mos, 8 mos)
• Mortality
3
 7 mo old - NEC
 10 day old – CHD
 21 day old with
esophageal disruption
at intubation
Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEF
Conversion to Open
5 Pts
• 1 Pt:
R aortic arch
(despite negative ECHO)
• 3 Pts:
Intraoperative desaturation,
relatively long gap
• 1 Pt:
1.2 kg baby – only 1 port placed
– too small
Thoracoscopic Repair EA/TEF
104 Patients
Waterston A
62 Patients
Waterston B
30 Patients
Waterston C
12 Patients
Operation converted
2
2
1
Operation staged
1
-
-
Esophageal anastomotic leak
2
3
3
Stricture (on initial esophagram)
3
1
-
Patients needing only 1 dilation
7
5
-
Patients needing 2 dilations
Patients needing 3 dilations
9
-
1
3
2
1
Patients needing >3 dilations
3
2
-
Recurrent tracheoesophageal fistula
1
1
-
Fundoplication
19
6
1
Imperforate anus operations
4
4
2
Duodenal atresia repairs
-
2
2
Aortopexy
Death
6
1
1
-
2
Waterston A: > 5.5 lb with no significant associated problems
Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly
Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly
Thoracoscopic Repair EA/TEF
Current
Number of
Patients
Mean length of
hospitalization
(days)
Anastomotic leak
Anastomotic
stricture
Patients requiring
at least 1 dilation
Anastomotic
revision
Fundoplication
Aortopexy
Mortality Related
EA/TEF
Not Related
Recurrent fistula
N.R.:
A:
B:
C:
D:
Engum, et al
(1971-93)
174
Spitz, Kelly
(1980-84)
18.1
(6-120)
N.R.
7.6%
N.R.
104
B
3.8%
C
32.7%
Randolph, et al
(1982-88)
39
Manning, et al
(1977-85)
63
N.R.
N.R.
24
(9-174)
21%
10.2%
17%
17.7%
33.3%
4.3%
148
A
D
31.7%
32.7%
N.R.
33.3%
N.R.
1.9%
0.9%
2.7%
5.1%
N.R.
24.0%
6.7%
25.2%
N.R.
18%
16%
15.3%
N.R.
16.9%
4.7%
0.9%
1.9%
2.8%
1.9%
4.5%
(overall)
14.8%
(overall)
2.2%
12%
0%
7.6%
7.6%
5.1%
3.1%
11.1%
14.2%
6.4%
Not reported
87% are Gross Type C
Stricture is defined as a significant narrowing on the initial esophagram
Stricture in this paper is defined as requiring > 4 dilations
Stricture in this paper is defined as requiring > 2 dilations
EA/TEF
Operative Approach
Thoracoscopy
Thoracotomy
• Transpleural
• Extrapleural/Transpleural
• Longer operative time
• Shorter operative time
• Better visualization
• Adequate visualization
• Anesthesia important
• Anesthesia standard
Thoracoscopic Repair EA/TEF
Advantages of Thoracoscopy
• Avoidance of
musculoskeletal sequelae
• Superior visualization of
anatomy
• Easy to identify fistula for
ligation
How To Get Started
Not The Ideal Case
• 2 - 2.5 kg
• Very high upper pouch
• Complex single
ventricle physiology
• Prostaglandin
dependent
How To Get Started
Ideal Case
• Baby – 2.5-3 kg; no other
anomalies
• Esophageal segments close
together (CXR,
Bronchoscopy)
• Start thoracoscopically –
Go as far as comfortable
• Try it again
Development of a Surgical Technique
Thoracoscopic Lobectomy – Lessons Learned
• Upper lobes are very difficult, esp. if training
residents
• Middle & lower lobes are easier b/c are “end
organs”
• Single lung ventilation very helpful – need good
anesthesiologist
• For prenatally discovered CPAM, better to wait
until baby is 6-9 mos of age (assuming
asymptomatic)
Development of a Surgical Technique
Thoracoscopic Lobectomy – Lessons Learned
Atlas of Pediatric Laparoscopy and Thoracoscopy
Holcomb, Rothenberg, Georgeson
Development of a Surgical Technique
SSULS
• Why did it develop?
• Who benefits
patient or surgeon?
• What operations are applicable?
• Special equipment needed?
SSULS
What Operations Are Applicable?
• Appendectomy
• Cholecystectomy
• Splenectomy
• Ileal or colonic resection (IBD or segmental
lesion) – extra-corporeal anastomosis
• Pyloromyotomy
SSULS
Special Equipment
• SILS port
(Covidien, Inc.)
• Cholecystectomy
• Splenectomy
• Segmental ileal or
colonic resection
•
Long telescope (300, 450)
SSULS
Cholecystectomy
SSULS
Appendectomy
SSULS
Appendectomy
Refinement in Technique
Lap. Fundoplication
• Cautery in pts <4-5 yrs
• Minimal esophageal
dissection/mobilization
Refinement in Technique
Lap Pyloromyotomy
Definition of Perforated
Appendicitis
Hole In appendix
Fecalith in abdomen
J Pediatr Surg 43:2242-2245, 2008
Definition of Perforated
Appendicitis
Impact of Strict Definition of Perforation on
Abscess Rate
Acute appendicitis
Perforated appendicitis
Before definition
After definition
Abscess rate (%)
Abscess rate (%)
1.7
0.8
14.0
18.0
J Pediatr Surg 43:2242-2245, 2008
Evidence Based Studies in MIS
Laparoscopic vs Open Pyloromyotomy
Preoperative Data
Open
(n = 100)
(mean +/- SE)
Laparoscopic
(n = 100)
(mean +/- SE)
P
value
Age (wk)
5.24 +/- 0.25
5.33 +/- 0.21
0.77
Preoperative pyloric
thickness (mm)
4.17 +/- 0.08
4.16 +/- 0.09
0.88
Preoperative pyloric
length (mm)
19.51 +/- 0.26
19.38 +/- 0.27
0.74
Admission chloride level
(mmol/L)
99.36 +/- 0.79
99.76 +/- 0.76
0.72
Admission bicarbonate
level (mmol/L)
28.18 +/- 0.51
27.86 +/- 0.47
0.65
Ann Surg 244:363-370, 2006
Evidence Based Studies in MIS
Laparoscopic vs Open Pyloromyotomy
Outcomes
Operating time
(minutes:seconds)
Postoperative emesis (no.)
Time to full feeds
(hours:minutes)
Doses of analgesia (no.)
Length of stay after
operation (hours:minutes)
Open
(n = 100)
(mean +/- SE)
Laparoscopic
(n = 100)
(mean +/- SE)
P
value
19:28 +/- 0:41
19:34 +/- 0:46
0.93
2.61 =/- 0.32
1.85 +/- 0.15
0.05*
21:01 +/- 1:17
19:30 +/- 1:22
0.43
2.23 +/- 0.18
1.59 +/- 0.15
0.008*
33:10 +/- 1:35
29:38 +/- 1:36
0.12
Ann Surg 244:363-370, 2006
Thoracoscopic Debridement vs Fibrinolysis
for Empyema
Patient Variables at Consultation
VATS
tPA
P Value
Age (Years)
4.8
5.2
0.77
Weight (kg)
24.6
20.7
0.52
WBC
20.8
19.7
0.71
O2 support (L/min)
0.81
0.79
0.96
Days of Symptoms
9.0
10.6
0.32
ER/PCP visits
2.9
2.7
0.69
J Pediatr Surg 44:106-111, 2008
Thoracoscopic Debridement vs Fibrinolysis
for Empyema
Outcomes
VATS
tPA
P Value
LOS (Days)
6.89
6.83
0.96
O2 tx (Days)
2.25
2.33
0.89
PO Fever (Days)
3.1
3.8
0.46
Analgesic doses
22.3
21.4
0.90
Patient Charges
$11,660
$7,575
0.01
16.6% failure rate for fibrinolysis
J Pediatr Surg 44:106-111, 2008
London Prospective Trial
VATS v Fibrinolysis w/Urokinase
• No difference in LOS (6 v 6 days)
• No difference in 6 month CXR
• VATS more expensive ($11.3K v $9.1K)
• 16 % failure rate for fibrinolysis
Am J Respir Crit Care Med 174:221-227, 2006
Current Management Algorithm
Treatment algorithm for empyema in children based on level 1 evidence.
Evidence Based Studies in MIS
Initial Laparoscopic Appendectomy vs Initial Non-operative
Management for Patients Presenting with Appendicitis and
Abscess
Patient Characteristics at the Time of Admission
Initial
operation
(n = 20)
Initial non-operative
management (n = 20)
P
value
Age (y)
10.1 +/- 4.2
8.8 +/- 4.2
.31
Weight (kg)
37.0 +/- 16.2
37.1 +/- 20.8
.98
Body mass index (kg/cm2)
18.0 +/- 4.5
19.5 +/- 5.5
.39
White blood cell count
17.4 +/- 6.6
16.9 +/- 6.8
.84
Maximum temperature
37.8 +/- 1.0
37.7 +/- 0.9
.95
Maximum axial area of abscess (cm2) 29.2 +/- 29.7
26.2 +/- 21.1
.75
APSA, 2009
J Pediatr Surg 45:236-240, 2010
Evidence Based Studies in MIS
Initial Laparoscopic Appendectomy vs Initial Non-operative Management for
Patients Presenting with Appendicitis and Abscess
Initial operation
(n = 20)
Initial non-operative management
(n = 20)
P value
62.1 +/- 38.7
42.0 +/- 45.5
.06
6.5 +/- 3.8
6.7 +/- 6.6
.92
20%
25%
1.0
Doses of narcotics
9.7 +/- 4.0
7.1 +/- 15.8
.47
Total health care visits
2.8 +/- 1.1
4.1 +/- 1.0
<.001
No. of CT scans
1.5 +/- 0.7
2.1 +/- 1.1
0.4
$44,195 +/$19,384
$41,687 +/- $18,483
.68
Operation time (min)
Total length of
hospitalization (d)
Recurrent abscess after
initial treatment
Total charges
APSA, 2009
J Pediatr Surg 45:236-240, 2010
MIS Studies in Progress
• SSULS Appendectomy vs 3-Port Lap Appendectomy
• SSULS Cholecystectomy vs 4-Port Lap
Cholecystectomy
• SSULS Splenectomy vs 4-Port Laparoscopic
Splenectomy
• Irrigation/Suction vs Suction Only During Lap.
Appendectomy for Perforated Appendicitis
• Epidural vs PCA for Post-operative Pain Mgmt.
Following Nuss Repair
Development of the Stab Incision
Technique
The Use of Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller Myotomy (7)
Appendectomy (102)
Meckel’s Diverticulum (2)
Pyloromyotomy (77)
Cholecystectomy (31)
Pullthrough (20)
Splenectomy (21)
Adrenalectomy (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Totals (511)
Used/case
1
2
2
2
2
1
2
2
2
2
1
1
1
714
Saved/case
4
3
3
1
1
2
2
1
2
2
2
2
2
1337
PAPS, 2003
J Pediatr Surg 38:1837-1840, 2003
Cost Savings from Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller (7)
Appy (102)
Meckel’s (2)
Pyloric (77)
Chole (31)
Pullthrough (20)
Spleens (21)
Adrenal (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Total = 511
Step Pt./Instit. Savings ($)
117,040 / 51,832
5,880 / 2,604
2,940 / 1,302
14,280 / 6,324
280/ 124
21,560 / 9,548
8,680 / 3,844
2,800 / 1,240
5,880 / 2,604
1,680 / 744
4,200 / 1,860
1,400 / 620
560 / 248
$187,180/$82,894
Ethicon Pt./Instit. Savings ($)
76,912 / 4,276
3,864 / 1,722
1,932 / 861
9,384 / 4,182
184 / 82
14,168 / 6,314
5,704 / 2,542
1,840 / 820
3,864 / 1,722
1,104 / 492
2,760 / 1,230
920 / 410
368 / 164
$123,004/$54,817
PAPS, 2003
J Pediatr Surg 38:1837-1840, 2003
What Advances Will Be Made in
the Next Decade?
QUESTIONS
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