REMOVED: Successful management of an Iatrogenic portal vein and hepatic artery injury in a 4-month-old female patient: A case report and literature review.

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Post-operative anterior diaphragmatic hernias in children with Trisomy 21 after cardiac surgery.

Morgagni hernias account for less than 5% of congenital diaphragmatic hernias. They are characteristically retrosternal and bilateral, with right-sided predominance. An association between Trisomy 21 and diaphragmatic hernias resembling Morgagni hernia has been reported, but the effect of cardiac surgery on its formation has not been investigated. The purpose of this study was to determine whether there is a higher incidence of anterior diaphragmatic hernias in children with Trisomy 21 after cardiac surgery. We compared the prevalence of anterior diaphragmatic hernias in 92 patients with Trisomy 21 who underwent cardiac surgery with its prevalence in 100 children without Trisomy 21 who underwent cardiac surgery. All available CXRs of all children underwent revision for the presence of an anterior diaphragmatic hernia by a pediatric radiologist. Within the study group, four cases of an anterior diaphragmatic hernia were detected, all upon presentation to the emergency room due to breathing difficulties. No cases of an anterior diaphragmatic hernia were found in the control group (P = 0.0094). CONCLUSIONS: A high index of suspicion for an anterior diaphragmatic hernia should be maintained in children with Trisomy 21 who have undergone cardiac surgery and present with breathing difficulty. If CXR findings are uncertain, UGI series and\or CT should be performed. In light of our findings, the surgical technique has been modified in patients with DS in our medical center. WHAT IS KNOWN: • Several studies reported an association between Trisomy 21 and diaphragmatic hernia resembling Morgagni hernia, but the effect of cardiac surgery on its formation has not been investigated. WHAT IS NEW: • There is a higher incidence of anterior diaphragmatic hernia resembling a Morgagni hernia in children with Trisomy 21 after cardiac surgery. • A high index of suspicion for an anterior diaphragmatic hernia should be maintained in children with Trisomy 21 who have undergone cardiac surgery and present with breathing difficulty. If CXR findings are uncertain, UGI series and\or CT should be performed.

Deformability of cord blood vs. newborns' red blood cells: implication for blood transfusion.

AIM: About 50% of premature neonates (PN) are treated with transfusion of packed red blood cells (PRBC) collected from adult donors, which has been suggested to potentially provoke PN pathologies, characterized as blood circulation disorders. RBC have properties that are key determinants of blood circulation, primarily the cell deformability. In previous studies we have shown that transfusion of RBC with reduced deformability impaired the transfusion outcome. Although RBC of PN (PN-RBC) are larger, and their microvessels are narrower than those of adults, their blood circulation is very efficient, pointing to the possibility that the deformability of adults' PRBC is inferior to that of PN-RBC, and that treating PN with PRBC transfusion might, therefore, introduce a risk to the recipients. This would infer that PN should be given RBC with high deformability. However, since using PN-RBC is not feasible, the use of cord blood RBC (CB-RBC) is a sound alternative, assuming that the deformability of CB-RBC is comparable to that of PN-RBC.The present study is aimed at testing this hypothesis. METHODS: We compared the deformability of (1) RBC of PN vs. the PRBC they received, and (2) PN-RBC vs. their autologous CB-RBC. RESULTS: 1. The deformability of the transfused PRBC is indeed inferior to that of PN-RBC. 2. The deformability of CB-RBC is equivalent to that of PN-RBC. CONCLUSION: This study supports the notion that treating PN with transfusion of adults' PRBC has the potential to introduce a circulatory risk to the recipients, while CB-RBC, with their superior deformability, provides a safer and more effective PN-specific transfusion therapy.

Neonatal thrombotic microangiopathy secondary to factor I variant with Hirschsprung disease.

Neonatal thrombotic microangiopathy (TMA) is a rare and severe disease characterized by a triad of non-immune hemolytic anemia, thrombocytopenia, and organ dysfunction in neonates. We describe herein an early-term infant who underwent hemicolectomy at 4 days of age due to intestinal perforation. Following surgery, the patient had recurrent bouts of vomiting and abdominal distention, together with acute kidney injury, non-immune hemolytic anemia, and severe thrombocytopenia. Low complement levels raised the possibility of complement-mediated neonatal TMA. Finally, genetic tests identified a heterozygous mutation in the complement factor I gene. Anti-C5 monoclonal antibody therapy led to complete cessation of the hematological and renal manifestations, but symptoms of intestinal obstruction recurred. Intestinal biopsy demonstrated aganglionosis, compatible with Hirschsprung disease. This presentation is the first known case of neonatal complement-mediated TMA associated with Hirschsprung disease. Moreover, it highlights the importance of considering a diagnosis of TMA in cases of atypical neonatal infectious presentation.

The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study.

BACKGROUND: As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic. METHODS: A retrospective cohort analysis was performed between December 2019 and April 2020 in the four high-volume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA. RESULTS: A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis. CONCLUSIONS: The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

Outcomes of laparoscopic sleeve gastrectomy in patients older than 60 years.

BACKGROUND: Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown. METHODS: A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18 < age < 50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities. RESULTS: Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9 ± 0.3 years). These were matched to 104 young patients, age 18-50 years (mean age, 35.7 ± 0.8 years). Groups did not differ in male gender (44 vs. 43%, p = 0.9), preoperative BMI (42.6 ± 0.7 vs. 42.6 ± 0.6, p = 0.97), and length of follow-up (17 ± 2 vs. 22 ± 1.4 months, p = 0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65%, p < 0.001). Excess weight loss (EWL) was higher in the younger group (75 ± 2.4 vs. 62 ± 3%, p = 0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9%, p < 0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8%, p < 0.001). This included atrial fibrillation (9.5%), urinary tract infection (7%), trocar site hernia (4%), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2%, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80%, p = 0.13). CONCLUSIONS: LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.