No abstract

In adult patients, laparoscopic surgery, using a robot system (Da Vinci, Intuitive Surgical, Mountain View, California), has been recently introduced into surgical practice. To investigate the feasibility of the system in paediatric surgery, laparoscopic fundoplications as well as cholecystectomies have been performed. In July 2000 we used the robot system for the first time on an 11-year-old girl with gastro-oesophageal reflux, and since that time on 7 other children. Altogether 5 Thal and 3 Nissen procedures have been carried out. The average age was 12 years, with a range of 7 to 16 years. All operations were performed without complications and without conversion to open surgery. The medium operating time was 146 min with a range of 105 to 180 minutes. Compared to conventional laparoscopy, the 3-dimensional high-quality vision, the advanced instrument movements and the ergonomic position of the surgeon seems to enhance surgical precision. In our opinion, the use of the robot system is feasible and safe in paediatric surgery. The technique is limited due to the fact that instruments adapted to the size of small children are not yet available.

For the intensivist, the successful use of rFVIIa in these patients and others lacking pre-existing coagulopathies points to rFVIIa as a novel therapeutic approach for patients presenting with massive life-threatening hemorrhage.

The aim of our study was to evaluate the success, complications, and morbidity following a modified Thal fundoplication in children with reflux‐associated respiratory disease (RARD). We used a procedure consisting of retroesophageal hiatal plasty, wrapping the gastric fundus around the gastroesophageal junction 180°, and fixation of the lesser curvature at the abdominal wall. Follow‐up by questionnaire of 128 (77 male, 51 females) out of 196 antireflux procedures between 1992 and 1995 was achieved. Surgical therapy was considered justified whenever there was gastroesophageal reflux resulting in severe recurrent respiratory symptoms. Eleven percent of the children suffered from bronchiectasis. The diagnosis of RARD was based on a high index of suspicion, barium swallow with fluoroscopy, 24‐hr two‐level pH‐monitoring, bronchoscopy, bronchoalveolar lavage and detection of lipid‐laden alveolar macrophages, esophago‐gastroscopy, and esophageal biopsy. Patients with bronchopulmonary diseases such as allergy, immunodeficiency, cystic fibrosis, primary ciliary dyskinesia, and malformation of the bronchial tree or vessels had been excluded. “Evident improvement” as a result of surgery was reported in 88%, “no change” in 10%, and a “change for the worse” in 2% of patients. Persistent mild difficulties in swallowing were observed in 11%. Paraesophageal hernia, gas‐bloat syndrome, and dumping syndrome were not observed. Two children needed a second operation because of relapse. The use of emergency steroidal medication for acute respiratory distress decreased impressively (219 single doses/year before surgery vs. 30 single doses/year after surgery). The need for more than 4 times/year of antibiotic therapy before surgery was reduced from 52.3% before to 14% after surgery. Most (90.6%) of the parents stated they would agree to have surgery done again if medically indicated. In conclusion, Thal fundoplication is sufficient, safe, and effective in the management of RARD. Complications of the procedure were minor and of little consequence to the patient. Pediatr Pulmonol. 1999; 28:89–93. © 1999 Wiley‐Liss, Inc.

We report on our experience with two patients with pheochromocytoma. One patient underwent surgery of pheochromocytoma at the age of 30 y; 18 y later, medullary thyroid carcinoma (MTC) was detected in his son. Subsequently, multiple endocrine neoplasia (MEN) type 2A was diagnosed by genetic examination in both father and son. Further diagnostic procedures also revealed an MTC in the father. The other patient suffered from bifocal pheochromocytoma of the left suprarenal gland. Diagnostic work‐up revealed papillary thyroid carcinoma, which was also detected in the mother 8 mo later. Whereas a point mutation in SDHB gene was found in the son, no genetic abnormality was detected in the mother. Conclusion: Every pheochromocytoma in childhood warrants further diagnostic work‐up, including genetic examination. In addition, clinical data of patients suffering from pheochromocytoma and papillary thyroid carcinoma should be collected by an international registry, and a joint effort should be undertaken in order to define possible underlying mutated genes in these patients.