Conjugate Multimode Heat Transfer Analysis of Cryogenic EXLO Manipulation.

In this study, a conjugate radiation/conduction multimode heat transfer analysis of cryogenic focused ion beam (FIB) milling steps necessary for producing ex situ lift out specimens under cryogenic conditions (cryo-EXLO) is performed. Using finite volume for transient heat conduction and enclosure theory for radiation heat transfer, the analysis shows that as long as the specimen is attached or touching the FIB side wall trenches, the specimen will remain vitreous indefinitely, while actively cooled at liquid nitrogen (LN2) temperatures. To simulate the time needed to perform a transfer step to move the bulk sample containing the FIB-thinned specimen from the cryo-FIB to the cryo-EXLO cryostat, the LN2 temperature active cooling is turned off after steady-state conditions are reached and the specimen is monitored over time until the critical devitrification temperature is reached. Under these conditions, the sample will remain vitreous for >3 min, which is more than enough time needed to perform the cryo-transfer step from the FIB to the cryostat, which takes only ∼10 s. Cryo-transmission electron microscopy images of a manipulated cryo-EXLO yeast specimen prepared with cryo-FIB corroborates the heat transfer analysis.

Use of trans-anastomotic tubes in congenital duodenal obstruction.

AIM: Despite data to suggest benefit of trans- anastomotic tube (TAT) feeding in infants following repair of congenital duodenal obstruction (CDO), TAT usage is limited. We aimed to report a large series of infants with CDO treated with or without TAT in order to improve the evidence underlying this simple intervention. METHOD: Single centre retrospective review of all infants CDO over a 20-year period (January 1999 - November 2020, inclusive). Important outcomes were compared between infants treated with or without TAT. Data are median [IQR]. RESULTS: Ninety-six infants were included. A TAT was placed in 54 infants (56%). Median time to full enteral feed was significantly shorter in the TAT group (6 [5-8] days vs 10 [7.5-12], p <0.001). Time to first feed was shorter in the TAT group (2 [2-2.8] days vs 3 [2-5], p<0.001). Significantly fewer infants with a TAT placed received a central venous catheter (CVC, 15% vs 76%, p <0.001). Infants without a TAT received parenteral nutrition (PN) for longer (0 [0-0] vs 7 [0-11] days, p <0.001). There was no change in length of stay between TAT and no TAT group (16 [13-21.8] vs 15 [12-21.8] days, p = 0.722). Eight infants (15%) in the TAT group required a CVC and PN. One infant in the TAT group developed a perforation that required surgical management and nine infants in the non-TAT group had complications related to the CVC (21%), including one infant that required general anaesthetic for tunnelled central line placement (2.3%). CONCLUSION: In infants with CDO, TAT use was associated with earlier establishment of full enteral feeds, reduced need for CVC and PN and reduced complications. Further research should focus on the barriers to wider use of TAT by surgeons and neonatologists in infants with CDO.

Remission of Type II Diabetes Mellitus 1-Year Postoperative Following One Anastomosis Gastric Bypass in Correlation with ABCD, DiaRem, and DRS Scores.

BACKGROUND: Diabetes mellitus (DM) is a debilitating chronic illness. Roux en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) present a potential solution to type II DM. Several scoring systems predict DM remission as ABCD score, DiaRem score, and diabetes remission score (DRS). STUDY DESIGN: This was a retrospective study that included 138 patients with DM and underwent OAGB. BMI, HbA1C, insulin, and oral hypoglycemics need were recorded pre- and postoperatively with calculation of ABCD, DiaRem, and DRS scores. Effects of OAGB on DM were observed and correlated with the scoring systems to detect their sensitivity and specificity. RESULTS: Age, preoperative, and postoperative BMI were 47.38 ± 7.632, 45.096 ± 4.465, and 31.173 ± 3.799 respectively. The preoperative and stimulated C-peptides were 3.357 ± 0.995 and 4.158 ± 0.897 ng/ml respectively. The preoperative and postoperative HbA1C were 7.396 ± 0.743% and 6.564 ± 0.621% respectively. Patients with complete remission were 32 patients (23.2%) and with partial remission were 46 patients (33.3%) adding to 56.5% considered in remission. There was significant decrease of BMI, HbA1C, insulin, and oral hypoglycemic use postoperatively. Receiver operator characteristics (ROC) curve showed that ABCD, DiaRem, and DRS scores had AUC of 0.853 with cut-off > 5, 0.921 with cut-off ≤ 8, and 0.805 with cut-off ≤ 8 respectively. The DiaRem score had the highest AUC followed by ABCD score then DRS score. CONCLUSION: OAGB significantly reduced BMI and HbA1C values 1 year postoperatively with 56.5% DM remission. DiaRem score had more remission predictive value following OAGB than ABCD and DRS scores especially when ≤ 8 with 90.6% sensitivity and 83% specificity.

Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic Roux-en-Y Gastric Bypass Effects on Pre-existing Mild-to-Moderate Gastroesophageal Reflux Disease in Patients with Obesity: a Randomized Controlled Study.

BACKGROUND: Patients with obesity having GERD usually undergo Roux-en-Y gastric bypass (RYGB) as the procedure of choice. However, the emergence of one anastomosis gastric bypass (OAGB) as a less time-consuming operation with fewer complications offers a potential option for these patients. STUDY DESIGN: This randomized controlled trial included 80 patients (out of 457 screened) with mild-to-moderate GERD that were equally divided into two groups for OAGB and RYGB. GERD was diagnosed by 20-item questionnaire, upper endoscopy, 24-h pH monitoring, and manometry. Follow-up at 6 and 12 months was done. RESULTS: No significant differences were found between the two groups regarding demographic data, comorbidities, and weight loss. OAGB had less operative time and fewer complications. Both procedures had comparable favorable effects in reducing the GERD symptoms evidenced by upper endoscopy, 24-h pH monitoring, and manometry. CONCLUSION: OAGB is a promising bariatric procedure in weight loss for patients with obesity having mild-to-moderate GERD (up to grade B esophagitis by Los Angeles score). Furthermore, wide-scale studies and on more severe degrees of GERD are required to fully understand its benefits in GERD patients with obesity.

Magnet ingestion in children and its implications: tertiary centre experience.

BACKGROUND: Swallowing multiple magnets or a magnet and second metallic object can carry risks of intestinal obstruction, fistula and perforation because they can attach to each other with loop of bowel in between. An updated management plan and reviewing our experience are warranted because of increased incidence of magnets ingestion among children. METHODS: All the patients who had a history of single, multiple magnet or single magnet and second metallic object ingestion in Bristol Royal Hospital for children during the period from January 2014 till November 2020 were included in our study. RESULTS: A total of 46 patients were referred to our hospital with a history of magnet ingestion. The number of magnets ingested ranged between one and twenty one magnets. All patients had abdominal x-ray undertaken either Antero-posterior alone (AP) (n = 32) or both AP and lateral (n = 14). Surgical intervention was performed in 18 patients; Oesophago-gastro-duodenoscopy (n = 8), laparotomy/laparoscpy (n = 10) to retrieve the magnets or deal with the complications. CONCLUSIONS: Magnets ingestion in children can be tricky when it comes to management. Complications can happen quite often and carry severe risks on children. An updated structured algorithm is proposed to manage children with magnet ingestion.

Neuroblastoma with an unusual ovarian metastasis in a 5-year-old girl.

Neuroblastoma metastasizing to the ovary is rare. We report the 10th case and review the scarce literature. A 5-year-old girl with stage M neuroblastoma presented with an upper abdominal and a pelvic mass. Evaluation after induction showed very good tumour response with three remaining localisations: two abdominal and one pelvic. At gross total resection, the pelvic mass appeared to be the enlarged and abnormal right ovary and was removed completely. Pathology showed an ovarian metastasis. On completion of her postoperative treatment, she achieved complete remission. Literature review showed that underdiagnosing of ovarian metastasis in neuroblastoma is very likely.

Too Many Biopsies Performed to Rule Out Hirschsprung's Disease: But It is Worth Doing Them.

INTRODUCTION: The U.K. National Institute for Health and Clinical Excellence (NICE) specify the following indications for performing rectal biopsy to rule out Hirschsprung's disease (HSD): (1) passage of meconium > 48 hours; (2) constipation since first few weeks of life; (3) chronic abdominal distension with vomiting; (4) family history of HSD; and (5) faltering growth in addition to any other indication. The aim of this study was to assess the compliance of a tertiary referral center with the current U.K. NICE guidelines for performing rectal biopsies to rule out HSD. Secondary aims included assessing alternative indications and complication rates. MATERIALS AND METHODS: Retrospective analysis of patients undergoing open or suction rectal biopsies to investigate HSD, from 2009 to 2014. RESULTS: A total of 188 patients underwent 214 biopsies (suction: n = 154, open: n = 60). Note that 128 patients (68.1%) had biopsies indicated by NICE. A total of 84.4% of indicated biopsies were ganglionic versus 91.7% of unindicated biopsies (p = 0.17). Twenty-five patients were diagnosed with HSD (mean age: 13.2 weeks, range: 3 days-3.2 years). Only 80% of HSD patients had NICE-indicated biopsies. Presentations for patients with biopsies not indicated by NICE included constipation, distension, and vomiting that did not strictly meet the guidelines. The majority of biopsies were uncomplicated (suction 82.5% vs. open 95.0%)-inadequate/indeterminate histology was the most common complication (16.2% suction vs. 5% open). CONCLUSION: A significant number of unindicated biopsies were performed, the majority of which were ganglionic. Rectal biopsies are generally safe and strict adherence to the NICE guidelines could have led to missed HSD diagnoses with potential significant morbidity and mortality.

Paediatric liver transplantation for metabolic disorders. Part 2: Metabolic disorders with liver lesions.

Liver based metabolic disorders account for 10 to 15% of the indications for paediatric liver transplantation. In the last three decades, important progress has been made in the understanding of these diseases, and new therapies have emerged. Concomitantly, medical and surgical innovations have lead to improved results of paediatric liver transplantation, patient survival nowadays exceeding 80% 10 year after surgery with close to normal quality of life in most survivors. This review is a practical update on medical therapy, indications and results of liver transplantation, and potential future therapies, for the main liver based metabolic disorders in which paediatric liver transplantation may be considered. Part 1 focuses on metabolic based liver disorders without liver lesions, and part 2 on metabolic liver diseases with liver lesions.

Paediatric liver transplantation for metabolic disorders. Part 1: Liver-based metabolic disorders without liver lesions.

Liver-based metabolic disorders account for 10 to 15% of the indications for paediatric liver transplantation. In the last three decades, important progress has been made in the understanding of these diseases, and new therapies have emerged. Concomitantly, medical and surgical innovations have lead to improved results of paediatric liver transplantation, patient survival nowadays exceeding 80% 10-year after surgery with close to normal quality of life in most survivors. This review is a practical update on medical therapy, indications and results of liver transplantation, and potential future therapies, for the main liver-based metabolic disorders in which paediatric liver transplantation may be considered. Part 1 focuses on metabolic based liver disorders without liver lesions, and part 2 on metabolic liver diseases with liver lesions.

Serous and seromucinous infantile ovarian cystadenomas--a study of 42 cases.

The rarity of infantile ovarian cystadenoma (CA) accounts for the very little knowledge about their behaviour. The aim of this retrospective study is to highlight the modes of presentation and to evaluate the treatments and the recurrence risks of these benign tumours. Relation to adult epithelial ovarian tumours is discussed. The medical records and imaging studies of 42 CA in 31 children less than 16 years of age operated at our institution between 1985 and 2003 were retrospectively evaluated. Mean age of first surgery was 11.5 years. 7/31 girls (22.6%) presented with a bilateral CA, four of them were synchronous. 8/42 (19%) CA were in torsion at surgery, conservative management was possible in four cases. 31/42 (74%) CA were treated conservatively. 4/42 CA recurred 1-3.5 years after complete cyst removal. All were endocervical type CA, there was no intestinal type. The 42 CA were serous in 18/42, mucinous in 23/42 and unqualified in one. Mucinous epithelial cells were often sparse and focal along the cyst wall. Four CA presented with micropapillae in post-pubertal girls. No borderline tumours were observed. Mucinous cystadenomas (MCA) are better described as seromucinous cystadenoma (SMCA) because of the mucinous cells localisation. CA occurs early in life, we surmise that they may need hormonal stimulation to develop micropapillae. Complete removal of these potentially low-grade malignant ovarian tumours precursors is advocated. Conservative surgery is recommended to preserve ovarian function.

Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases.

INTRODUCTION: The authors describe and discuss the clinical and therapeutic features of 40 ovarian torsions (OT) in children with its urgent treatment that has advanced in recent years. MATERIALS AND METHODS: A retrospective study of 40 cases of OT in 38 children under 16 years of age, excluding adnexal torsions in neonates. RESULTS: Abdominal and/or pelvic pain was the presenting symptom ; 8 of these children had pain between 2 to 9 months prior to surgery and 27/40 (67.5%) had associated vomiting. Before the procedure, ultrasound (US) diagnosed 29 ovarian lesions, related to 14 mature teratomas (MTE) and 10 cystadenomas (CA), one association of MTE and CA in the same ovary, 2 functional cysts and 2 malignant neoplasms. 19/40 torsions could benefit from conservative management. Eleven torsions occurred, 10/11 of these ovaries had an increased volume, and 5/11 had US evidence of small subcortical cysts. Three detorsions with incomplete removal of CA were followed by enlargement of the tumor and re-torsion in 2 of them. Five children had bilateral ovarian pathology which led to unilateral ovariectomy, while the other benefited from conservative treatment. CONCLUSIONS: In any girl presenting with abdominal pain, the diagnosis of an ovarian torsion must be considered. US is performed emergently, but only surgery, most often a laparoscopic procedure, assures diagnosis. The treatment of the torsion is an emergency and must be as conservative as possible in order to preserve the ovarian function. Bilateral torsions are not unusual.

Immunological monitoring after organ transplantation: potential role of soluble CD30 blood level measurement.

Analysing the relevance of soluble CD30 (sCD30) in the bloodstream before and after transplantation may be important for the monitoring of transplant recipients. In this study, 27 patients (15 pediatric liver and 12 adult kidney graft recipients) were investigated. In the liver graft group, the patients who developed acute rejection during the first month (n=9) had a slightly higher sCD30 value on pre-transplantation baseline (day 0) and post-transplantation day 7, when compared to patients with normal graft function (n=6) (day 0: 102(1.6) U/ml versus 118(1.5) U/ml, p=0.52) and (day 7: 69(1.5) U/ml versus 83(1.6) U/ml, p=0.47). Increased serum sCD30 was shown to correlate with increased interleukin-10 circulating levels between day 0 and day 7 (r=0.53; p=0.04), whereas, no correlation could be evidenced between interferon-gamma (IFN-gamma) and sCD30 (r=0.02; p=0.47). Similarly, in the kidney transplantation group, no significant difference was found in sCD30 levels at day 0 in both groups with graft rejection or normal graft function (n=6) (85(1.3) U/ml versus 77(1.6) U/ml, p=0.66), but sCD30 decreased significantly at day 7 post-transplantation from baseline value in the rejection group (n=6) (77(1.6) versus 35(1.4); p=0.02). We conclude that increased serum sCD30 was correlated with increased IL-10 (interleukin-10) circulating levels, but not with IFN-gamma levels in the post-transplantation period. Neither pre-transplantation sCD30 nor sCD30 at day 7 post-transplantation could be correlated with acute rejection in liver graft recipient. The monitoring of sCD30 might constitute a tool to assess the risk of acute rejection in renal transplant but did not appear as a valuable mean for early immunological monitoring in the small group of liver allograft recipients patients analysed in this study.

Pyloric obstruction, duodenal dilatation, and extrahepatic cholestasis: a neonatal triad suggesting multiple intestinal atresias.

Whereas physiologic jaundice constitutes a common finding in neonates, a few cases present with cholestatic jaundice owing to various pathologic conditions, including extrahepatic biliary obstruction. We report the case of a 2-day-old female neonate presenting with neonatal cholestasis, nonbilious vomiting with pyloric obstruction, and multiple intestinal atresias. A pathognomonic clinicoradiologic triad is described, based on clinical data, plain abdominal x-ray, and ultrasound examination.

Pediatric liver transplantation using left hepatic segments from living related donors: surgical experience in 100 recipients at Saint-Luc University Clinics.

Living-related liver transplantation was developed in the context of deceased donor organ shortage, which is particularly acute for pediatric recipients. This retrospective study analyzes the surgical technique and complications in the first 100 pediatric liver transplantation using left segmental liver grafts from living donors, performed at Saint-Luc University Clinics between July 1993 and April 2002. Pre-operative evaluation in donors and recipients, analysis of the surgical technique, and postoperative complications were reviewed. After a median follow-up period of 2526 days, no donor mortality was encountered, with a minimal morbidity and no long-term sequelae. At one and five yr post-transplantation, the actuarial patient survival rates were 94% and 92%, the corresponding figures being 92% and 89% for graft survival. The incidences of portal vein and hepatic artery thromboses, and of biliary complications were 14%, 1%, and 27%, respectively. Living-related liver transplantation in children constitutes an efficient therapy for liver failure to face the increased demand for liver grafts. Donor morbidity was kept to acceptable incidence, and surgical technique in the recipient needs to be tailored to minimize postoperative complications.

Permanent access to the portal system for cellular transplantation using an implantable port device.

A novel application of the implantable Port-a-Cath (PAC) system is described in the context of cellular transplantation. A silicone catheter was inserted in a collateral branch of the portal vein and connected to a port device positioned subcutaneously on the left thoracic cage. This permanent vascular access allowed iterative intraportal infusions of allogenic hepatocytes without the need of repeated transhepatic catheterization of the portal vein. Using this technique, repeated infusions of cryopreserved and / or fresh hepatocytes were successfully carried out in 3 children with inborn errors of liver metabolism, with the aim of progressively providing a sufficient mass of transplanted liver cells to stabilize the metabolic condition of the patients. We suggest that this technique might also be valuable in pancreatic islet cell transplantation.