Implementation of Enhanced Recovery After Surgery protocols for gastrostomy tube insertion in patients younger than 14 years of age: a retrospective cohort study.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have improved treatment outcomes and have standardized patient care. OBJECTIVES: Identify the benefit of introducing the ERAS protocol for feeding after gastrostomy insertion with or without Nissen fundoplication, the effects on the time of reaching the full feeds the length of stay single-center experience, and complications associated with early feeding protocols. DESIGN: Retrospective cohort study SETTING: Tertiary hospital METHODS: The study review included cases performed between 2015 and 2021 by four surgeons, and cases performed in 2022 by all surgeons using ERAS feeding protocol (P) in a tertiary hospital. MAIN OUTCOME MEASURES: Comparison the mean and mode of the length of stay (LOS) and the time until the patient reached full feed (TFF). SAMPLE SIZE: 224 patients; 181 by the four surgeons and 43 cases by the ERAS protocol group. RESULTS: The difference in the ERAS protocol from the four surgeons in TFF and LOS was statistically significant (P<.001). There was no noticeable difference in postoperative complications after introducing the ERAS protocol. CONCLUSION: ERAS improved the TFF and decreased the LOS without any increase in procedure complications. Increasing bed utilization and reducing costs were two benefits of reducing LOS at our hospital. LIMITATIONS: Single-center study, which may not be generalizable. Multiple comorbidities. Travel time from different parts of the country could impact LOS. Retrospective and thus dependent on the accuracy of the information in file notes. CONFLICT OF INTEREST: None.

Soft tissue mass of the chest wall as the sole manifestation of brucellosis in a 7-year-old boy.

We report the case of a child who presented with a subcutaneous mass on the left side of the chest wall of one month's duration. The mass was painful and increasing in size over time. He had a history of weight loss and a decrease in appetite, but no history of fever or trauma. He had ingested raw camel milk, but had no history of contact with animals. He was diagnosed by the standard tube agglutination titer and tissue culture for brucellosis, treated with surgery and three months of antibrucella antibiotics. The report includes a brief review of the current pediatric literature to familiarize pediatricians with this uncommon presentation.

Pediatric short bowel syndrome: adaptation after massive small bowel resection.

BACKGROUND: Short bowel syndrome (SBS) develops after massive small bowel resections. Patients with less than 12 cm of jejunoileum have a slim possibility of being weaned from parenteral nutrition (PN). PATIENTS AND METHODS: In a retrospective review of records of consecutive patients with SBS, 8 patients were evaluated for treatment by adaptation and weaning from PN. These included 4 patients with class I SBS (0-10 cm of small bowel), one with class II SBS (>10-25 cm), one with class III SBS (>25-50 cm), and 2 with class IV SBS (>50-75 cm). Adaptation was assessed by measuring growth in the small bowel and the ability to be weaned from PN. RESULTS: Adaptation was achieved primarily by extending the length of jejunoileum by approximately 450% over the first 2.5 years after resection and by increasing the degree of colonic fermentation and absorption of nutrients. As of July 1, 2005, all of the patients were off PN, with the exception of 2 patients with class I-A SBS: patient 3 had a remaining jejunoileum of only 2.5 cm and patient 4 had a remaining jejunoileum of 9 cm but developed eosinophilic enterocolitis. These 2 patients continued with PN on alternate months. CONCLUSIONS: Bowel growth after massive small bowel resection provides an objective parameter of adaptation and a means of predicting ability to be weaned from PN. Aggressive nutritional support makes even patients with class I SBS, whose disease was previously considered hopeless, likely candidates to achieve freedom from PN.

Persistent hyperinsulinaemic hypoglycaemia of infancy in 43 children: long-term clinical and surgical follow-up.

OBJECTIVE: To describe the clinical, surgical, biochemical, radiological and electrophysiological features of 43 Saudi children with persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI) who have been followed since 1983. METHODS: Data from 43 patients were retrospectively analysed. PHHI was diagnosed on the basis of high intravenous glucose requirement, high insulin to glucose ratio, negative urinary ketones and normal tandem mass spectrometry. The patients were assessed radiologically by brain magnetic resonance imaging and/or computed tomography and electrophysiologically by brain stem auditory evoked potential, visual evoked response and electroencephalogram. Patients who failed medical therapy received near total pancreatectomy. RESULTS: The patients were severely hypoglycaemic and intolerant to fast. Hypoglycaemic convulsion was the most commonly presenting complaint. Eighteen patients were developmentally delayed and 14 of them had brain atrophy. All patients, except nine, did not respond to medical treatment and underwent surgery. Four pancreatectomized patients developed diabetes and two had malabsorption. One baby had 180 cm resection of gangrenous bowel most likely secondary to octreotide. No common bile duct injury was encountered. One patient was treated medically during childhood and developed diabetes and gained weight during adolescence. CONCLUSION: PHHI is a relatively common and serious disease among Saudi children. Early intervention is necessary to avoid neurological damage in patients who are severely hypoglycaemic and unresponsive to medical therapy. Surgically and probably medically treated patients are at a high risk of developing diabetes, which could be the natural outcome of this disease. Care and spending time during surgery to visualize the common bile duct help in avoiding its injury.

Gastroesophageal reflux following repair of esophageal atresia and tracheoesophageal fistula.

OBJECTIVE: This study represents the experience of a tertiary care center in the Kingdom of Saudi Arabia (KSA) on the long-term effect on the lungs of esophageal atresia (EA) and tracheoesophageal fistula repair (TEF), and to emphasize the magnitude of gastroesophageal reflux (GER) post-EA or post-TEF repair. METHODS: A retrospective review of all patients referred to the pulmonary clinic with EA/TEF or re-operative evaluations from the period 1993-2004 at King Faisal Specialist Hospital and Research Centre, Riyadh, KSA. RESULTS: Forty-one patients with confirmed EA/TEF (26 males and 15 females) were included in the study. Congenital anomalies were associated in 28 (68%). Gastroesophageal reflux developed in 39 (95%) of patients, 24 (59%) needed Nissen fundoplication. Esophageal stricture that required more than 3 dilations developed in 16 (46%) patients, esophageal dysmotility in 37 (90%) and hiatal hernia in 11 (27%). Pulmonary complications developed in >70% of the patients including persistent atelectasis, chronic aspiration pneumonia, asthma and chronic lung disease that required oxygen for more than one month. Tracheomalacia in 12 (29%) and bronchiectasis in 7 (17%). Eighty-eight percent of patients who were able to do pulmonary function test showed abnormal values of moderate obstructive and restrictive lung disease. CONCLUSION: Pulmonary complications cause significant and prolonged morbidities post EA/TEF repair. Gastroesophageal reflux is a common complication after EA/TEF repair and causes significant morbidity that needs a prolonged follow up. Patients with GER may need Nissen fundal plication to improve respiratory problems.