SURGICAL GRAB BAG
| THE CHILD WITH A HERNIA —Jacob C. Langer, MD, Professor, Department of Surgery, University of Toronto Faculty of
Medicine, and Chief of General Surgery, Hospital for Sick Children, Toronto, ON
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| Introduction: in children, almost all inguinal hernias indirect, ie, patent processus vaginalis with something coming
through it; most commonly contain fluid, bowel, or (in girls) ovary
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| Fluid: fills processus vaginalis to form communicating hydrocele; noncommunicating hydrocele—formed when processus
vaginalis obliterated proximally, trapping fluid distally; most common in very young children, eg, seen in ≈25% of
boys in newborn nursery; fluid usually absorbed over time, so in children <2 yr of age, hydrocele not repaired; communicating
hydrocele—due to small patency of processus vaginalis in child >2 yr of age; fluid remains and hydrocele not getting
smaller; repair indicated because patent processus vaginalis may allow formation of bowel hernia in future
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| Bowel: reducible inguinal hernia containing bowel must be repaired because it is sometimes symptomatic (child crying)
and because of risk for incarceration; incarcerated hernia—in adults, nonreducible (by definition); however, in children
>95% can be reduced by experienced pediatric surgeon; so in children, defined as hernia that cannot be reduced by referring
physician or emergency department (ED) physician; in adults, concern about bowel ischemia, while in children, concern
about testicular ischemia and necrosis (bowel necrosis rare in children); effect of age—the younger the child, the
more likely hernia will become incarcerated; in newborns, ≥25% of bowel hernias become incarcerated if unrepaired during
first year; in older children, risk for incarceration extremely low, and repair considered elective surgery
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| Management of incarcerated hernia: if hernia cannot be reduced by experienced ED physician (<5% of cases), repair
indicated; difficult operation because sac thin, structures small, and chance of injuring spermatic cord or having recurrent
hernia extremely high; exploration of other side—10% of children with symptomatic hernia on one side develop
hernia on contralateral side in future; patent processus vaginalis found in 50% of contralateral sides when explored, ie,
only 1 in 5 patent processuses develops into clinical hernia, so exploration controversial; risk factors for contralateral
hernia—age (most important; higher in younger children); prematurity; sidedness; increased intra-abdominal pressure;
at speaker’s institution, contralateral side not explored in majority of children
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| Who should perform repair: data show recurrence rate about twice as high when general surgeons perform repair as
when done by pediatric surgeons; general surgeons who do high volume of pediatric hernia repairs have better outcomes
and lower recurrence rates
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| PERFORATED APPENDICITIS IN CHILDREN —J.T. Gerstle, MD, Assistant Professor of Surgery, University of Toronto,
Faculty of Medicine, and Program Director, Division of General Surgery, Hospital for Sick Children, Toronto
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| Introduction: incidence of perforation—in children <3 yr of age, almost 100%; in children <5 yr of age, >80%; overall,
36%; reasons for perforation—poor communication with child who may be preverbal; misdiagnosis as gastrointestinal
(GI) problem not requiring surgery; socioeconomic factors, eg, ethnicity, access to health care, insurance, referral patterns
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| Tests: scoring system—weighted elements include nausea, anorexia, cough, tenderness to percussion, and right lower
quadrant; as score exceeds 6 to 7, number of children with appendicitis increases dramatically; ultrasonography (US)—
high specificity, but range of sensitivity broad and operator-dependent; obesity and intra-abdominal air make interpretation
difficult; computed tomography (CT)—excellent specificity and sensitivity; not operator-dependent; not affected by
obesity; however, caution required because of high radiation exposure (effective radiation dose from CT of abdomen and
pelvis for children equivalent to 1300 chest x-rays); when in doubt, re-examine patient (can observe child for 12-24 hr
with <2% incidence of perforation)
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| Treatment: intravenous (IV) fluids; antibiotics—regimens include ceftriaxone, ticarcillin, and piperacillin-tazobactam;
10-day course of therapy suggested (shorter at speaker’s institution); criteria for discharge include no fever for 24 hr on
regular diet; antibiotic course completed at home; percutaneous drainage—hastens recovery; effective in children who
are septic, who have large accessible fluid collections, or who have complications related to appendicitis; children with
small multiple inaccessible collections best treated with antibiotics alone; complications—include effusions in chest,
bowel obstruction, and sepsis; almost all clear with antibiotic regimen, and surgery typically not needed; interval
appendectomy—controversial; risk for recurrence 7% to 14%; risk increased if appendicolith present; proceed with interval
appendectomy (with parents’ consent) if fecalith present; 80% of pediatric surgeons recommend interval appendectomy,
regardless of whether fecalith present
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| Practice guidelines: algorithm—child evaluated by surgeon; if diagnosis equivocal, US or CT recommended; if diagnosis
still equivocal, observe child; if diagnosis not made, child referred to pediatrician
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| CHRONIC PANCREATITIS AND ISLET AUTOTRANSPLANTATION —Hobart W. Harris, MD, MPH, Professor and Chief
of General Surgery, University of California, San Francisco, School of Medicine
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| Review of chronic pancreatitis: benign disease characterized by debilitating pain, anorexia and food fear, and evidence
of exocrine insufficiency, eg, steatorrhea, diarrhea with foul-smelling stools; malnutrition and weight loss; after 7 to 8 yr,
severe disease evolves into type 2 diabetes; condition chronic and relapsing; causes—ethanol use >80 g/day; cause unknown
in 5% to 10% of patients; 5% of patients have other causes, including pancreas divisum, hereditary pancreatitis,
hyperlipidemia, autoimmune pancreatitis, and genetic polymorphisms; histopathology—progressive fibrosis causing
scarring of parenchyma and replacement of exocrine pancreas by scar tissue in focal, segmental, or diffuse pattern; end-
stage disease shows glandular atrophy, ductal ectasia, and sequential strictures and dilations of pancreatic duct, as well as
stones and calcifications in parenchyma and lumen
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 | Orphan disease: classically defined as disease that provides little incentive to pharmaceutical industry to make and market
medications to treat or prevent it, usually because of low incidence (<200,000 patients total) or prevalence mostly in
underdeveloped countries; other definitions—affected population politically, socially, or economically disenfranchised
and unsympathetic; un chronic pancereatitis association with alcohol abuse leads to stigmatization that disease brought
on by weakness of character or addictive personality; this contributes to lack of interest in study of pathophysiology or
development of effective therapies
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| Incidence: 80,000 new cases annually in United States; estimated cost $65 million for acute care; because patients in prime
of life (40-60 yr of age), earning power and contribution to society affected; male predominance; associated with increased
risk for pancreatic cancer (25-fold increase found in some studies); worldwide incidence—0.5% overall
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| Treatment options: opiates, sometimes supplemented with pancreatic enzymes; octreotide; ablation of celiac plexus with
ethanol or sclerosing agents or surgical interruption; endoscopic procedures—include sphincterotomy, placement of stents,
dilation of strictures; surgical procedures—decompression of dilated duct; resections; total pancreatectomy; condition
treated as if related to increased ductal and/or parenchymal pressure
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| Islet autotransplantation: inclusion criteria—patients with benign disease undergoing total or subtotal pancreatectomy;
patients undergoing partial pancreatectomy who may need completion pancreatectomy in future; nondiabetic or
mildly diabetic patients; social support system, including multidisciplinary health care providers; exclusion criteria—
malignancy; diabetes; active alcohol or substance abuse
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| Procedure: harvesting of islets; administration of heparin to patient before reinfusion; infusion of islets into portal circulation
of liver (requires low baseline portal venous pressures; monitor during infusion); complications include portal
hypertension, infection, or infarction of liver; place patient on insulin drip to keep glucose 80 to 100 mg/dL for first 2 to
3 days after transplantation, to rest islets
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| Technique: pancreas removed, isolated, and perfused with digestive enzymes to remove connective tissue; islet cells collected
in isolation chamber; pancreatectomy completed and continuity of GI tract reestablished; harvested islets injected
into portal circulation through mesenteric tributary; if concerned about possible malignancy, perform percutaneous pancreatectomy
in radiology suite, examine specimen, and reinfuse islets on postoperative day 1
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| Patient profiles: 45% idiopathic or familial pancreatitis; 20% with pancreas divisum; 20% with history of alcohol use;
10% had pancreatitis secondary to biliary disease; 40% of patients had previous surgery, eg, Puestow (most common),
distal pancreatectomy, Whipple procedure
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| Results: ability to harvest islet cells determined by type of previous surgery; number of islet equivalents harvested ranges
from 92 to >12,000/kg body weight; previous decompressive Puestow procedure dramatically decreases ability to recover islets;
distal pancreatectomy leads to decreased yield of islets; previous Whipple procedure associated with good recovery of
islets; number of islets transfused correlates with ability of patient to be insulin-free after transplantation; patients who received
>2500/kg body weight of islet equivalents have 3 in 4 chance of being insulin-free, with chance decreasing as number
of islet equivalents decreases; pain—in study, 40% of patients pain-free; 33% dramatically improved (greatly decreased requirement
for pain medication); 10% had no change or got worse; 16% lost to follow-up; even patients who still have some
pain and must take insulin report greatly improved quality of life and state that they would choose transplantation again;
case presentation—man, 41 yr of age, went from being totally disabled for 7 yr to being almost pain-free and leading normal
life
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| CHECKLIST FOR SAFE ESOPHAGEAL SURGERY —Richard C. Karl, MD, Richard G. Connar, Professor and Chair, Department
of Surgery, University of South Florida College of Medicine, Gainesville
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| Safety in aviation: accident rate has decreased ≈87% since 1960s; due to crew working together and communicating
with each other in patterned manner that allows clear exchange of information; emphasis on situational awareness; use of
checklists; no-fault reporting system for near-misses
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| Precautions in esophageal cancer: must know whether patient has distant disease, whether tumor locally unresectable
(use endoscopic US; positron emission tomography [PET] and CT also used), and whether patient can tolerate surgery
(use standardized pulmonary and cardiac clearance tests; look for other confounding variables or morbidities that
may affect outcome)
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| Endoscopic US: highly effective for detection of local lymph node involvement (T staging); much more effective than
CT; PET used liberally to determine distribution of disease; appearance of distant metastases on PET gives information
on patient’s comfort and ability to swallow
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| Pulmonary function testing: done routinely, since most common postoperative complications involve respiratory system
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| Medical evaluation: comprehensive; 87% of patients smoke, and 84% use alcohol; cardiac risk stratification—based on
clinical predictors, including unstable angina or recent myocardial infarction (MI); stress testing; β-blocker
prophylaxis—most patients have ≥1 indication for this; colonoscopy—patients with esophageal cancer at high risk for
other GI malignancies; bowel preparation—mild; IV antibiotics on day of surgery; psychologic preparation—booklet
to tell patients about details of operation and what to expect
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| Checklists for operating room (OR) on day of surgery: universal protocol (time out; 2004)—discussion must
be held before operation to ensure right patient, correct site, and whether consent form matches procedure scheduled;
slight increase in number of wrong-side operations in following year; does not work because not woven into fabric of
everyday work, as shown by name, ie, “time out”
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| Frequently overlooked: temperature—mild hypothermia related to 3-fold increase in wound infections and to increased
length of stay in hospital; adjust OR temperature for patient’s comfort, not surgeon’s; tight glucose control—4-fold increase
in site infections after noncardiac surgery if patient’s blood glucose allowed to exceed 200 mg/dL; often little or
no discussion between surgeon and anesthesiologist about glucose control; blood transfusions—associated with infection;
in patients undergoing surgery for malignancies of GI tract, associated with increased recurrence; shown to have
immunosuppressive effect that affects long-term outcome; talk to anesthesiologist about not giving unit of blood just
because patient becomes slightly hypotensive; IV fluid restriction—several papers demonstrate patients “flooded” with
1500 mL of IV fluid before surgery and another 3000 ML in OR do not do as well as those in whom fluid restricted
(fewer complications)
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| Preoperative check in holding area: done with anesthesiologist in front of family; ask patient if he or she has had recent
changes in symptoms or medications; get to know names of patient and family; ask about swallowing (if metastasis found,
may consider palliative surgery in patient who cannot swallow, but not in one who can); give family estimate of how long
surgery will take and warn them that certain conditions found in surgery may preclude removal of esophagus
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| In OR: discuss operative site and fluid restriction with anesthesiologist; ensure that antibiotics and prophylaxis for deep
venous thrombosis were administered; every 30 min, discuss patient’s temperature, blood glucose, and urine output,
and check whether all equipment working
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| Standard emergency checklist: printed algorithm of steps to take if something goes wrong
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| Presurgical briefing on whiteboard: patient’s name; name(s) of family waiting; names of OR staff
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| “Descent” checklist: instrument counts; items more likely to be left behind when surgery has been emergency, operation
changed from one originally intended, or patient obese; order x-ray as closing occurs
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| Long-term results: depend on attention paid to matters in immediate postoperative period, especially reconciliation of
medications before discharge
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Suggested Reading
Adibe OO et al: Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous
antibiotics versus early conversion to an oral regimen. Am J Surg 195:141, 2008; Ahmad SA et al: Factors associated
with insulin and narcotic independence after islet autotransplantation in patients with severe chronic pancreatitis. J Am Coll
Surg 201:680, 2005; Beddy P et al: Inguinal hernia repair protects testicular function: a prospective study of open and
laparoscopic herniorraphy. J Am Coll Surg 203:17, 2006; Blondet JJ et al: The role of total pancreatectomy and islet autotransplantation
for chronic pancreatitis. Surg Clin North Am 87:1477, 2007; Bundy DG et al: Does this child have appendicitis?
JAMA 298:438, 2007; Geisler DP et al: Laparoscopic exploration for the clinically undetected hernia in
infancy and childhood. Am J Surg 182:693, 2001; Jamadar DA et al: Characteristic locations of inguinal region and anterior
abdominal wall hernias: sonographic appearances and identification of clinical pitfalls. AJR Am J Roentgenol
188:1356, 2007; Kaminski A et al: Routine interval appendectomy is not justified after initial nonoperative treatment of
acute appendicitis. Arch Surg 140:897, 2005; Karl RC et al: Factors affecting morbidity, mortality, and survival in patients
undergoing Ivor Lewis esophagogastrectomy. Ann Surg 231:635, 2000; Kokoska ER et al: Effect of pediatric surgical
practice on the treatment of children with appendicitis. Pediatrics 107:1298, 2001; Livingston EH et al:
Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management.
Ann Surg 245:886, 2007; Lym L et al: Risk of contralateral hydrocele or hernia after unilateral hydrocele repair in
children. J Urol 162:1169, 1999; Morrison CP et al: Islet yield remains a problem in islet autotransplantation. Arch
Surg 137:80, 2002; Nguyen TN et al: Laparoscopic and thoracoscopic Ivor Lewis esophagectomy with colonic interposition.
Ann Thorac Surg 84:2120, 2007; Paterson HM et al: Changing trends in surgery for acute appendicitis. Br J
Surg 95:363, 2008; Pennathur A et al: Resection for esophageal cancer: strategies for optimal management. Ann Thorac
Surg 85:S751, 2008; Rampado S et al: Endoscopic ultrasound: accuracy in staging superficial carcinomas of the
esophagus. Ann Thorac Surg 85:251, 2008; Rathaus V et al: Ultrasound features of spermatic cord hydrocele in children.
Br J Radiol 74:818, 2001; Roach JP et al: Complicated appendicitis in children: a clear role for drainage and delayed
appendectomy. Am J Surg 194:769, 2007; Ron O et al: Systematic review of the risk of developing a metachronous
contralateral inguinal hernia in children. Br J Surg 94:804, 2007; White SA et al: Pancreas resection and islet autotransplantation
for end-stage chronic pancreatitis. Ann Surg 233:423, 2001.
Educational Objectives
| The goal of this program is to improve the surgical management of hernias and perforated appendicitis in children and report
on progress made in islet autotransplantation for chronic pancreatitis and use of checklists to improve safety in surgery
for esophageal carcinoma. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Evaluate the child with an incarcerated hernia.
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| 2. Use a scoring system and imaging techniques to diagnose perforated appendix in a child.
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| 3. Describe the treatment of perforated appendix in a child, including antibiotic therapy, percutaneous drainage, and
possible interval appendectomy.
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| 4. Review the etiology and histopathology of chronic pancreatitis, and describe the technique and current results for
pancreatectomy with islet cell autotransplantation.
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| 5. Explain how the use of checklists can improve outcomes in surgery for esophageal cancer.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, Dr. Karl reports being the Founder of the Surgical
Safety Institute. Drs. Langer, Gerstle, and Harris and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Langer and Gerstle addressed Update in General Surgery 2007, presented March 29-31, 2007, in Toronto, ON, by
the University of Toronto Faculty of Medicine, Department of Surgery. Dr. Harris gave his lecture at The Postgraduate
Course in General Surgery, held March 22-24, 2007, in San Francisco, CA, and sponsored by the University of California,
San Francisco, School of Medicine, Department of Surgery. Dr. Karl appeared at 6th Annual Surgery of the Foregut
Symposium, held February 18-21, 2007, in Weston, FL, and sponsored by the Section of Minimally Invasive
Surgery and the Bariatric Institute of Cleveland Clinic Florida, in conjunction with the European Surgical Institute,
the Federation of Latin American Surgeons, and the Association of Latin American Endoscopic Surgeons. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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