Newborns with Bloody Stools-At the Crossroad between Efficient Management of Necrotizing Enterocolitis and Antibiotic Stewardship.

The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell's criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell's criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.

[Uretero-pelvic junction obstruction due to crossing pole vessel: contra vascular hitch]. / Subpelvine Stenose/Kreuzendes Gefäß ­ kontra vascular hitch.

Hydronephrosis in infants and children is most commonly due to a congenital, intrinsic obstruction of the uretero-pelvic junction. The Gold standard of care is defined as a dismembered pyeloplasty, nowadays mostly performed in a minimally-invasive procedure, either through a laparoscopic (also robotic-assisted) or retroperitoneoscopic approach. Less common is an extrinsic obstruction of the ureter or the uretero-pelvic junction caused by an aberrant crossing pole vessel, a condition more likely to affect children beyond infancy. This entity most often becomes apparent when it causes intermittent abdominal or flank pain. For this entity, Hellström described a surgical procedure avoiding dismembered pyeloplasty by hitching the crossing vessel in a tunnel at the pyelon. This has been increasingly advocated as a valuable therapeutic alternative to dismembered pyeloplasty. The discussion on whether dismembered pyeloplasty or a vascular hitch procedure is preferable to resolve the obstruction is controversial and ongoing. There is evidence in the literature that in the case of a crossing pole vessel an intrinsic stenosis of the ureter may additionally be present in up to 57 % of cases. However, this finding can only be proven histologically. The intraoperative aspect of a crossing pole vessel and the uretero-pelvic junction does not serve to discriminate between intrinsic and extrinsic stenosis. Therefore, a vascular hitch procedure bears the risk that a remaining intrinsic obstruction will be disregarded, which, in turn, may lead to urodynamic obstruction and consecutive loss of differential renal function. In addition, there is a general risk of compromising the perfusion of the affected kidney while hitching an aberrant vessel providing significant blood supply. Dismembered pyeloplasty can avoid a false selection of patients. In addition, there is sufficient evidence showing that dismembered pyeloplasty is a procedure with a low complication rate ranging from 2 to 3 %, providing very good results in functional outcome in terms of improving drainage and preserving differential renal function. Therefore, we prefer dismembered pyeloplasty as the method of choice for both the treatment of intrinsic as well as extrinsic uretero-pelvic junction obstruction.

A Suggestion on How to Compare 2D and 3D Laparoscopy: A Qualitative Analysis of the Literature and Randomized Pilot Study.

BACKGROUND AND AIMS: The results of studies comparing two-dimensional (2D) and three-dimensional (3D) laparoscopy have shown variable results. We aimed to review the literature and develop an appropriate instrument to compare 2D and 3D laparoscopy. We further aimed to use the data extracted to perform a pilot study. METHODS: Sixty-seven recent articles on 3D laparoscopy were reviewed and data extracted on factors influencing outcome variables. These variables were used to design a pilot study of 28 novices using a randomized crossover design. The results were analyzed using descriptive statistics and the Wilcoxon signed-rank tests. RESULTS: Seven themes were identified to influence the outcome of 3D studies: applied technique (1), experience of subjects (2), study design (3), learning curve (4), subjective qualitative reports (5), laparoscopic tasks (6), and chosen outcome variables (7). The consecutively developed five laparoscopic simulation tasks contained placing a rubber band over hooks, ring and pearl transfer, threading a pipe cleaner through loops, and placing a suturise. The pilot study showed a primary benefit of 3D laparoscopy that was unrelated to repetition. Two tasks served well to assess first-time performance, and two tasks promise to serve well to assess a learning curve if performed repeatedly. CONCLUSION: We were able to identify important issues influencing the outcome of studies analyzing 3D laparoscopy. These may help evaluate future studies. The developed tasks resulted in meaningful data in favor of 3D visualization, but further studies are necessary to confirm the pilot test results.