| Laparoscopy
is a standard technique utilized in many surgical procedures proving
itself important in as much as convalescence, less postoperative pain,
better cosmesis and less hospital stay refers. Inserting trocar
cannulas into the abdominal cavity can cause iatrogenic injury to
intraabdominal organs, namely, blood vessels, viscera and bladder.
Bladder injury during laparoscopy is very rare occurring with an
estimated incidence of 0.5% of all general surgery laparoscopic
procedures. The risk is increased in children due to smaller operative
field. Most cases of bladder injury occur during emergency procedures
performed in and toward the pelvis. Laparoscopic appendectomy is the
procedure most commonly associated with bladder injury in children.
Hollow organs should be decompressed to minimize damage to these
structures during laparoscopy. Placement of a bladder catheter (Foley)
during pelvic procedures, including appendectomy, reduces but does not
eliminate the possibility of causing injury to the bladder. Bladder
injury occurs during suprapubic trocar placement (most commonly) or
while dealing with an inflammatory procedure near the bladder. Bladder
injury can also occur if a urachal remnant is injured during suprapubic
trocar insertion. In the immediate postop period a child with
laparoscopic bladder injury will show suprapubic pain, hematuria,
urinary retention, urinary leakage from wound sites, cystitis or even a
subtle rise in creatinine. The systemic inflammatory response can
include suprapubic cellulitis and crepitation from an underlying
infection if the injury is delayed. Most trocar injuries produce a
through and through perforation of the bladder tangentially or
including two holes. The diagnosis of bladder injury is established
with contrast cystogram. Findings could be of extraperitoneal or
intraperitoneal bladder injury. Extraperitoneal injury can be managed
conservatively with bladder drainage and antibiotics. Intraperitoneal
bladder injury needs operative repair. References: 1- Levy BF, De Guara J, Willson PD, Soon Y, Kent A, Rockall TA: Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series. Ann R Coll Surg Engl. 94(3):e118-20, 2012 2- Lad M, Duncan S, Patten DK: Occult bladder injury after laparoscopic appendicectomy. BMJ Case Rep. 2013 Nov 22;2013. pii: bcr2013200430. doi: 10.1136/bcr-2013-200430. 3- Hotonu SA, Gopal M: Bladder injury in a child during laparoscopic surgery. J Surg Case Rep. 2019 Feb 19;2019(2):rjz043. doi: 10.1093/jscr/rjz043. eCollection 2019 Feb. 4- Deshpande AV, Michail P, Gera P: Laparoscopic repair of intra-abdominal bladder perforation in preschool children. J Minim Access Surg. 13(1):63-65, 2017 5- Godfrey C, Wahle GR, Schilder JM, Rothenberg JM, Hurd WW: Occult bladder injury during laparoscopy: report of two cases. J Laparoendosc Adv Surg Tech A. 9(4):341-5, 1999 6- Ostrzenski A, Ostrzenska KM: Bladder injury during laparoscopic surgery. Obstet Gynecol Surv. 53(3):175-80, 1998 |
| Lymphoma
arising primarily from the thyroid gland is a very uncommon malignancy
comprising less than 5% of all thyroid cancers and less than 2% of
extranodal lymphomas. Non-Hodgkin lymphoma of the thyroid gland has a
female predominance. Thyroid lymphoma can be confused with anaplastic
thyroid cancer in as much as both have rapid growth associated with
dyspnea, dysphagia, pain, stridor, coughing, choking and hoarseness of
voice. Most cases are euthyroid. Many cases of thyroid lymphoma have a
ten-year prior history of Hashimoto thyroiditis. Large cell lymphoma
probably evolves from persistent low-grade mucosa-associated lymphoid
tissue (MALT) malignant lymphoma. Fine needle aspiration cytology has a
limited role in diagnosing thyroid lymphoma since the cytological
differentiation from lymphocytic thyroiditis and anaplastic carcinoma
is difficult. A core needle or open biopsy is usually required to
diagnose thyroid lymphoma. Thyroid lymphoma can be confused with
anaplastic carcinoma needing differentiation using immunohistochemical
assays with antibodies to cytokeratin and leukocyte common antigens.
Most thyroid lymphomas are of B-cell origin predominantly diffuse large
cell type. This does not means that Hodgkin's, Burkitt, plasmacytoma
and T-cell lymphoma have also been reported in a lesser scale.
Management of thyroid lymphoma is based in the histologic subtype,
stage of disease and tumor bulk. In general treatment includes a
combination of monoclonal antibodies, chemotherapy and radiotherapy.
The presence of histopathological features of MALT constitutes a
favorable prognostic factor for high grade lymphomas with five years
survival of 90%. Lymphomas of non-MALT origin have a poorer prognosis
with 5 year survival of less than 50%. Factors predicting worse
prognosis include tumor size over 10 cm, advance stage, obstructive
local symptoms, rapid tumor growth and mediastinal involvement. With
this regimen of management the need for debulking and thyroidectomy has
been reduced in this condition unless the patient has airway
compromise. Secondary thyroid lymphoma originates from a disseminated
non-thyroidal neoplasia that metastasize to the thyroid gland with
widespread disease and higher mortality rates. References: 1- Sarinah B, Hisham AN: Primary lymphoma of the thyroid: diagnostic and therapeutic considerations. Asian J Surg. 33(1):20-4, 2010 2- Peixoto R, Correia Pinto J Soares V, Koch P Taveira Gomes A: Primary thyroid lymphoma: A case report and review of the literature. Ann Med Surg (Lond). 13:29-33, 2016 3- Gonzalves M, Gaspar E, Santos L, Carvalho A: When a Goitre is a Thyroid Lymphoma. Eur J Case Rep Intern Med. 2018 Dec 27;5(12):000999. doi: 10.12890/2018_000999. eCollection 2018. 4- Walsh S, Lowery AJ, Evoy D, McDermott EW, Prichard RS: Thyroid lymphoma: recent advances in diagnosis and optimal management strategies. Oncologist. 18(9):994-1003, 2013 5- Stein SA, Wartofsky L: Primary thyroid lymphoma: a clinical review. J Clin Endocrinol Metab. 98(8):3131-8, 2013 6- Sharma A, Jasim S, Reading CC, et al: Clinical Presentation and Diagnostic Challenges of Thyroid Lymphoma: A Cohort Study. Thyroid. 26(8):1061-7, 2016 |
| Dialysis
using the peritoneal surface is an effective temporary therapy used
widely in children and adults affected with end stage renal disease. A
viable catheter allowing adequate inflow and outflow of dialysate fluid
is essential for continuous peritoneal dialysis therapy to be
successful. Malfunctioning of the peritoneal catheter is a common
complication encountered during peritoneal Dialysis. Malfunctioning
might occur due to kinking, catheter migration out of the pelvis,
malpositioning of the tip, and obstruction of the catheter due to
debris or fibrin deposition, blood clots, omental wrapping or
intraperitoneal adhesions. The incidence of malfunctioning peritoneal
catheters used for dialysis can occur in more than 50% of patients.
Catheter related problems are blamed for up to 20% of patient transfers
to hemodialysis. When there is obstruction to flow of dialysate fluid
through the catheter some non-surgical maneuvers that can be
accomplished to salvage the situation include infusion of urokinase to
lyse the fibrin clot, forced flushing the catheter, the use of metal
guidewire or Fogarty catheters to manipulate and clear the way to flow.
Should this simple maneuvers failed to restore the catheter flow then
surgical intervention is warranted. This usually requires open surgical
removal and replacement of the catheter. Laparoscopy is a minimal
invasive technique alternative to rescue malfunctioning catheters under
direct vision. Using laparoscopy for reestablishment of flow through
the catheter we can identify the real cause of malfunctioning whether
is migration or obstruction and perform the necessary steps to correct
the problem. Migration of the catheter tip from the pelvis is the most
common laparoscopic finding found in malfunctioning peritoneal
cannulas. This is managed with repositioning of the tip in the pelvis.
This is followed by omental wrapping or dense adhesions as a cause of
obstruction. Partial omentectomy and adhesiolysis is necessary in such
situations to reestablish flow. Laparoscopy can also determine if the
peritoneal absorptive capacity is overturned and the child needs
removal of the catheter and commencement of hemodialysis. Catheter
survival rate of 60-90% at one year can be achieved after laparoscopic
salvage. References: 1- Alabi A, Dholakia S, Ablorsu E: The role of laparoscopic surgery in the management of a malfunctioning peritoneal catheter. Ann R Coll Surg Engl. 96(8):593-6, 2014 2- Beig AA, Marashi SM, Asadabadi HR, Sharifi A, Zarch ZN: A novel method for salvage of malfunctioning peritoneal dialysis catheter. Urol Ann. 6(2):147-51, 2014 3- Salgaonkar HP, Behera RR, Sharma PC, Katara A, Bhandarkar DS: Minimally invasive surgery for salvage of malfunctioning peritoneal dialysis catheters. J Minim Access Surg. 15(1):19-24, 2019 4- Maheshwari PN: Laparoscopy for continuous ambulatory peritoneal dialysis catheter placement and management of malfunctioning peritoneal dialysis catheter. J Minim Access Surg. 15(1):88-89, 2019 5- Kouri AM, Wilson AC, Nailescu C: A malfunctioning peritoneal dialysis catheter: Answers. Pediatr Nephrol. 32(3):441-442, 2017 6- Kouri AM, Wilson AC, Nailescu C: A malfunctioning peritoneal dialysis catheter: Questions. Pediatr Nephrol. 32(3):439-440, 2017 |
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