Expanding intestinal segment using osmotic hydrogel: An in vivo study.

Intestinal circumferential expansion is essential for bowel lengthening in patients with Short Bowel Syndrome. We hypothesized use of an endoluminal osmotic hydrogel expander (EOHE) as a novel approach for intestinal expansion. An EOHE was introduced into an isolated intestinal segment of New Zealand rabbits, with a similar segment created as a control. After 4weeks, the segments were retrieved for analysis. Weight, inflammatory markers and fluoroscopy data was recorded weekly. EOHE allowed successful expansion of intestinal segments from 4.68 ± 0.35 to 9.79 ± 0.35 cm (p = 0.01). Increase in intestinal length was 167.8 ± 35.21% in segments with EOHE vs. 23.03 ± 4.2% in the control group (p < 0.01). A significant intestinal dilatation (214.4 ± 1.58 vs. 34.59 ± 1.23%, p < 0.01) was demonstrated. Hematoxylin and eosin stain revealed conservation of intestinal architecture with muscle hypertrophy and flattening of the epithelium possibly due to compression. No reduction of rabbit weight, inflammatory markers or liver damage was described. EOHE appears to produce safe intestinal expansion, achieving increased length and dilatation suitable for lengthening procedure. This approach may allow development of similar techniques to expand bowel in short bowel patients. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1304-1309, 2019.

Complete Resolution of Retroperitoneal Lymphangioma with a Single Trial of OK-432 in an Infant.

Retroperitoneal lymphangioma is extremely rare. Although these neoplasms are benign, they can grow progressively with subsequent compression and infiltration of the adjacent structures. Surgical excision is demanding when the lesion surrounds vital structures and it is generally fraught with a high recurrence and morbidity rate. We report the case of a huge retroperitoneal lymphangioma in a newborn treated successfully with intracystic injection of OK-432.

Central venous catheter placement in children with thrombocytopenia.

BACKGROUND: The use of central venous catheter (CVC) is essential in the management of chronically ill children. Thrombocytopenia is a common hematological finding in these patients, with an increased risk of bleeding during the insertion of CVC. No clear guidelines are reported regarding the CVC positioning in patients with disorders of hemostasis, and prophylactic platelet (PLT) transfusions are still controversial. Aim of this study was to report the bleeding risk in pediatric patients with thrombocytopenia who underwent positioning of CVC. METHODS: A retrospective single-center study of all CVCs surgically inserted over a 2-year period (April 2011 - April 2013) at our institution was performed. Age, gender, diagnosis, type of CVC, hematological values (hemoglobin and PLT count, prothrombin international normalized ratio, active partial thromboplastin time) and post-operative bleeding complications were compared between patients with PLT count below (group A) and above 50×109/L (group B). RESULTS: Seventy-two CVC procedures were performed in 67 patients, with a median age of 45 months. Of these, 25 (35%) catheters were positioned in 25 patients included in group A and the remaining 47 (65%) in 42 patients in group B. All twenty-five cases in group A received a prophylactic PLT transfusion prior to the procedure. Bleeding complications were reported in only two cases in group A (8%). CONCLUSIONS: CVC placement in pediatric patients with thrombocytopenia can be safely performed. We believe a randomized multicenter study could be necessary to determine the benefit of PLT transfusions in children with a PLT count below the recommended level of 50×109/L.

Antenatal ultrasonographic features associated with segmental small bowel dilatation: an unusual neonatal condition mimicking congenital small bowel obstruction.

Segmental dilatation of the intestine (SDI) is an unusual condition presenting during the neonatal period, with symptoms of obstruction. Late diagnosed cases are also reported. The clinical polymorphism, and the lack of specificity of radiological investigations, make diagnosis difficult. Prenatal detection of abdominal cystic lesions or bowel dilatation has occasionally been reported to be associated with SDI. We herein report two cases of SDI, with a prenatal ultrasonographic suspicion of intestinal abnormality. In both infants, a dilatation of the ileum was found at surgery, without any evident site of obstruction or abnormal histology. SDI must be taken into consideration when a prenatal alert of possible bowel obstruction is not followed by postnatal clinical signs.

Extrinsic colonic obstruction by congenital fibrous band in an infant.

The finding of a congenital fibrous band during laparotomy for intestinal obstruction is extremely rare. Preoperative diagnosis is challenging and no characteristic radiological findings have been described. We report the case of a premature baby in whom incomplete intestinal obstruction was due to a congenital band originating from the duodeno-jejunal flexure and extending across the ascending colon.

Preventing posterior sagittal anoplasty 'cripples' in areas with limited medical resources: a few modifications to surgical approach in anorectal malformations.

BACKGROUND: Anorectal malformations (ARM) are the most common neonatal emergencies in Sub-Saharan Africa countries. Late presentation, lack of pediatric facilities and trained paediatric surgeons influence the outcome of these patients. This study reports a 5-year of experience in the management of ARM at the Orotta Referral Hospital in Asmara (Eritrea) and proposes some modified surgical approaches to minimize the risk of complications and the length of hospital stay. MATERIALS AND METHODS: We reviewed the records of 38 patients with ARM observed between September 2006 and April 2011. Since 2009 a modification of original posterior sagittal anorectoplasty (PSARP) was introduced, consisting in a long rectal stump (3 cms) closed and left at the perineal level, to be trimmed after two weeks. This avoided mucous spillage on the wound and prevented contamination. Post-operative course and outcome were evalued in the two group of patients divided according the type of surgical technique (Group A: Standard PSARP; Group B: Modified PSARP). RESULTS: There were 21 boys and 17 girls aged 4 days to 9 years (median age 182 days). Of the 38 patients, 2 infants died before surgery and 3 refused preliminary colostomy. Previously confectioned colostomies often required revision or redoing due to severe prolapse or malposition. When possible, primary sigmoid colostomy was performed. There were 15 patients in Group A and 18 in Group B. Wound infection or disruption were recorded in 7 cases (46%) in Group A and in 2 (11%) in Group B. Late complications were related to anal stenosis, which required long term dilatations. Three cases needed a PSARP redo (2 in Group A, 1 Group B). CONCLUSIONS: We believe that our simple modification of original PSARP technique could be of help lowering post-operative complications rate and reducing hospital stay. Family compliance is mandatory for long-term surgical success. A relevant time must be spent in training to stoma care and post-operative anal dilatation.

Successful management of congenital chylous ascites with early octreotide and total parenteral nutrition in a newborn.

Congenital chylous ascites (CCA) is a rare disease that results from maldevelopment of the intra-abdominal lymphatic system. Few cases have been described and no gold standard treatment has been defined so far. Octreotide, a somatostatin analogue, has been used for the treatment of CCA, but always after a failed conservative approach with fasting, total parenteral nutrition (TPN) or medium chain triglyceride (MCT) feeds. We report the case of a newborn with CCA treated by fasting, TPN and octreotide for a period of 15 days until the abdominal distension was successfully reduced at which point treatment was switched to an MCT formula. On day 25 the patient was breastfed and was discharged on day 33. No recurrence of chylous ascites was noted. Our experience highlights the successful treatment with TPN and octreotide as the first step for the conservative approach of CCA in a newborn, reducing the length of treatment and hospitalisation.

Intradiaphragmatic hybrid lesion in an infant: case report.

Hybrid lesions have elements of both congenital cystic adenomatoid malformation and bronchopulmonary sequestration. We report an unusual case of an infant treated for an intradiaphragmatic hybrid lesion. Although computed tomography remains the criterion standard imaging examination for planning the operation, the exact localization of such lesions may be discovered only at surgical exploration.

Jejunoileal Atresia: Factors Affecting the Outcome and Long-term Sequelae.

CONTEXT: Jejunoileal atresia (JIA) is a common abnormality. The outcome is conditioned by several variables. Nutritional problems, and long-term sequelae are described among those who survive. AIM: To correlate the type of JIA and its management to the outcome and long-term quality of life. SETTINGS AND DESIGN: Forty-three cases over a 17-year period (1992-2009). Perinatal data, management, and outcome were extracted from the clinical notes. The cases that had survived were contacted to get information about their present condition. MATERIALS AND METHODS: Morbidity and mortality were matched to maturity, birth weight, mode of diagnosis, type of JIA, associated anomalies, and management and duration of parenteral nutrition. Growth and quality of life in 34 cases were evaluated via a telephone interview at a minimum of one year from surgery. STATISTICAL ANALYSIS: Fisher test, Linear regression test, Kruskal-Wallis test, Dunn's comparison test. RESULTS: Male/Female ratio was 25/18 and median birth weight was 2.644 g. Prenatal diagnosis was recorded in 34%. Six patients (14%) had associated anomalies. Primary surgery was resection and anastomosis in 88% and temporary stoma in 12%. Length of the resected bowel ranged from 3 to 65 cm. Whenever multiple atresia was found, the bowel length was saved by multiple anastomosis. Three dehiscences and three adhesive obstructions required a reoperation. Two patients (4%) died due to a central catheter-related sepsis. Prenatal diagnosis did not influence the outcome and was associated with a higher rate of Cesarean deliveries. Interview, at a median of nine years, showed normal growth in 85%. One case of short bowel syndrome is still on parenteral support at 22 months. CONCLUSIONS: Preserving bowel length and reducing the recourse to stoma is the key to good outcome and growth. Sequelae are correlated with the type of atresia and length of residual bowel; however, they decrease their severity with time.

Promoting major pediatric surgical care in a low-income country: a 4-year experience in Eritrea.

BACKGROUND: Access to pediatric surgical care in many sub-Saharan African countries is strongly limited by lack of medical facilities, adequate transport system, and trained medical and nursing manpower. The mortality rate for major congenital abnormalities remains extremely elevated in this area of the world. Strong efforts have been spent during the past decades to elevate the level of pediatric surgery standards in these countries through cooperation programs acting through periodical medical missions or supporting local medical teaching institutions. This is a report of a partnership between an Italian Medical Institution and the Eritrean Ministry of Health with the goal to improve pediatric surgical standard of care in the country. METHODS: During the past 4 years, teams composed of two pediatric surgeons, a pediatric anesthetist, and a pediatric nurse regularly visited the Orotta Medical and Surgical Referral Hospital of Asmara (Eritrea) to offer modern surgical treatment to children with major congenital abnormalities and to offer academic training to local medical and nursing staff. The team worked in local health structures. A total of 714 patients have been visited and 430 surgical procedures have been performed during 35 weeks of clinical work. Among them were 32 anorectal malformations, 11 Hirschsprung's disease cases, 8 bladder extrophies, and many other major surgical problems, such as congenital intestinal obstructions, obstructive uropathies, and solid tumors. RESULTS: The standard of care has been based on the principle of researching sustainable solutions. Surgical options and timing of each procedure have been decided to reduce hospitalization and the recourse to temporary stomas, indwelling catheterization, and prolonged intravenous feeding. Posterior sagittal anorectoplasties (PSARP) and posterior vagino-anorectoplasty (PSVARP) were performed for anorectal malformations, introducing minimal technical variants to reduce the need for postoperative nursing. Endorectal pull-through of functional stoma was the treatment of choice for patients with Hirschsprung's disease because frozen sections were not possible. Eight late-referred bladder extrophy cases were all managed by internal diversion (Mainz II pouch). Solid abdominal tumors always came to observation weeks or months after the first symptoms appeared. No CT scan was available and indications of surgery were based on clinical symptoms only. Only 11 of 18 cases were resectable, and only 5 of them with favorable histology survived, 2 after adjuvant therapy abroad. A large number of hypospadias were observed at the mean age of 4.5 years. Failures of previous attempts at correction were frequently found. The postoperative complications rate progressively decreased with the use of dripping stents to avoid the risk of accidental catheter removal or kinking. CONCLUSIONS: On the basis of our experience, major pediatric surgery in many under-resourced areas of sub-Saharan Africa can be developed, taking care to adapt surgical options to local conditions. Late referral of many congenital abnormalities, the impact of local culture, difficulties to establish regular follow-up, and shortage of facilities and medical devices must always be kept in mind before transferring modern protocols of management. Strong efforts have been devoted to train local medical and nursing staff to establish pediatric surgical manpower to cope with a still largely unanswered demand of care in this area of Africa.

Fetal abdominal lymphangioma enhanced by ultrafast MRI.

Abdominal lymphangioma represents an uncommon congenital anomaly. Herein, we describe an unusual case, which on routine antenatal ultrasonography masqueraded as isolated ascites. Subsequent fetal MRI at 27 weeks' gestation implemented antenatal assessment of the lesion, prompting further investigations and straightforward postnatal treatment. Fetal MRI represents a valuable adjunct to antenatal ultrasonography for the evaluation of cystic abdominal masses.