Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes.

PURPOSE: Radiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice. METHODS: Retrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature. RESULTS: Both RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations. CONCLUSIONS: The choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient.

Management of post appendicectomy intra-abdominal collections: A volumetric cut off for drainage?

BACKGROUND: Intra-abdominal collections (IAC) are a common complication following appendicectomy, one of the most commonly performed emergency abdominal procedures in childhood. The option to drain a collection is frequently available but not always required. AIM: The aim of this study was to compare the outcomes of medically and procedurally-managed post appendicectomy IACs and suggest a method of standardising the need for intervention. METHODS: A single centre, retrospective review of children aged ≤ 16 years presenting between 2014 and 2019 was performed. Patient demographics, management, and outcome data were collected. IAC volume and surface area were calculated assuming a prolate spheroid or true ellipsoid depending on the number of dimensions reported. RESULTS: 60 patients (18%) of 334 patients developed an IAC post appendicectomy. Medical management was undertaken in 44 (73%), drainage in 12 (20%), and surgical washout in 4 (7%). Collection size was associated with failure of medical management: maximum diameter (p = 0.028), volume (p = 0.002), and surface area (p = 0.001). Collections with a volume of 2 ml/kg were significantly less likely to fail medical management than larger collections (0/33 vs 6/11; p < 0.0001). DISCUSSION: Not all post appendicectomy IACs require drainage. The relationship between collection volume and need for drainage is more closely assessed using a volume calculation rather than a single dimension measurement, particularly when adjusted for weight of the child. A cut off of 2 ml/kg appears to be a good objective measure for intervention and provides a communication tool for discussion amongst the multidisciplinary team. Prospectively collected multicentre data on this subject would be timely. LEVEL OF EVIDENCE: III.

Laparoscopic management of impalpable testes: comparison of different techniques.

PURPOSE: Laparoscopy is an important modality for management of impalpable testes. We present long-term outcomes of intra-abdominal testes managed by either single stage orchidopexy or two-stage Fowler Stephen's orchidopexy (FSO) over 12 years. METHODS: Data were prospectively collected and retrospectively analyzed on patients who underwent laparoscopy for impalpable testes between 1998 and 2010. Demographic data, intra-operative findings, management, histology and follow-up findings were collected and analyzed. Fisher's Exact test was used for statistical analysis. RESULTS: Laparoscopy was performed for 168 impalpable testes (78 left, 58 right and 16 bilateral). Patients were between 8 months and 15 years of age (median 1 year 10 months). Ninety-three testes were found to have cord structures entering the inguinal ring (canalicular), 65 were intra-abdominal and 10 had blind ending vas and/or vessel. Fifty-seven (34%) testes were atrophic and underwent orchidectomy; 100 (60%) testes underwent orchidopexy: either two-stage FSO (48) or single stage orchidopexy (52) and 10 (7%) had findings consistent with 'vanishing testes'. Histopathologically, the excised remnants (34%) showed no viable testicular tissue. The follow-up was a median of 8 months (3 months to 6 years). Four patients were lost to follow-up (two each after FSO and single stage orchidopexy) while, two FSO are awaiting follow-up. At follow-up, 36/44 testes (FSO) and 13/13 testes (single stage orchidopexy) are in the scrotum and of good size. Eight testes had atrophied after two-staged FSO. CONCLUSION: Canalicular testes are often difficult to palpate (55%). Laparoscopy allows direct visualization and definitive management. There is no statistically significant difference between the results following single stage orchidopexy or two-stage FSO for impalpable testes.

Retroperitoneal cystic lymphangioma: a rare presentation in childhood, treated laparoscopically.

Retroperitoneal cystic lymphangioma is a rare benign lesion of childhood. A 15-year-old girl underwent laparoscopic excision of such a cyst. On histopathological examination, the resection was complete. She had an uneventful recovery and remains asymptomatic. We report this in view of the rarity of this condition and also the unusual presentation of this case. Complete surgical excision via laparoscopy is a feasible option.

Investigation of recurrent deletion loci specific to conventional renal cell carcinoma by comparative allelotyping in major epithelial carcinomas.

OBJECTIVE: Loss of heterozygosity (LOH) studies were undertaken to investigate the consistently deleted loci/? tumor suppressor gene loci (TSG) on 3p in conventional renal cell carcinoma (cRCC). MATERIALS AND METHODS: LOH studies were performed by polymerase chain reaction (PCR) using 15 micro satellite markers mapped in region 3p12-p26 on 40 paired cRCC tumors and normal kidney at Stages I-IV. Simultaneously, fluorescent in-situ hybridization (FISH) studies were performed to investigate the allelic deletion of fragile histidine triad (FHIT). RESULTS: Our studies revealed three affected regions; 3p12.2-p14.1, 3p14.2-p21.1, and 3p24.2-p26.1 with differential frequencies in Group I (Stage I and II) and Group II (Stage III and IV). Incidence for D3S1234 (FHIT locus) and D3S2454 (3p13) was 75% and 83% in Group I and II, respectively. Comparative allelotyping in epithelial malignancies like lung, bladder, and breast tumors revealed LOH (frequency 14-20%) only in breast tumors for D3S2406, D3S1766 (distal to FHIT), and D3S1560 (distal to VHL, Von-Hippal Lindau). FISH using FHIT gene probe revealed deletions in cRCC (88%), breast (30%), and lung tumors (10%) with no deletions in bladder tumors and leukemias, signifying the importance of FHIT in the pathogenesis of tumors of epithelial origin. CONCLUSION: Our findings suggested FHIT deletion as an early and VHL deletion as an early and/or late event in cRCC. Additionally, studies also disclosed the recurrent deletions of flanking loci to FHIT and VHL in cRCC. The dilemma of interstitial or continuous deletion on 3p needs to be resolved by implementation of latest sensitive molecular techniques that would further help to narrow down search for TSG loci specific to cRCC, other than VHL and FHIT.

Utility of array comparative genomic hybridization in cytogenetic analysis.

Conventional comparative genomic hybridization (CGH), high-resolution oligonucleotide, and BAC array CGH have modernized the field of cytogenetics to enable access to unbalanced genomic aberrations such as whole or partial chromosomal gains and losses. The basic principle of array CGH involves hybridizing differentially labeled proband/test (e.g., tumor) and normal reference DNA on an array of oligonucleotide or BAC clones instead of normal metaphases as in conventional CGH. The sub-megabase resolution tiling BAC arrays are extremely useful for the analysis of acquired aberrations in cancer genomes. Array CGH can be extremely useful to identify the chromosomal makeup of marker and ring chromosomes, to define/delineate the precise location/bands involved in structural aberrations and the accurate localization of translocation breakpoints in both simple and complex karyotypes either alone or in combination with standard karyotype analysis.

Laparoscopic management and outcomes in non-functioning moieties of duplex kidneys in children.

AIMS: Retroperitoneal laparoscopic hemi-nephrectomy (RLHN) is a well tolerated, minimally invasive, although technically demanding, procedure for children with a non-functioning moiety in a duplex kidney. There is very little published data on the long-term follow up of such patients. We collected data to assess outcomes from our experience. METHODS: Data were retrospectively gathered on all patients who underwent RLHN at our institution between February 2003 and July 2008. Follow-up ultrasounds were obtained in all patients. RESULTS: RLHN was performed in 42 patients. All had a non-functioning moiety of a duplex kidney and in addition recurrent urinary tract infections (n=36), incontinence (n=5) or vesico-ureteric reflux (n=1). Median age at surgery was 3 years, 7 months (4 months-13 years, 10 months). One patient required conversion to open procedure due to low (pelvic) kidney. The median operating time was 90min (45-150min). Urine leak developed postoperatively in one patient and loss of function of the remaining moiety occurred in another patient. They were followed up for a median period of 11 months (1-51 months). CONCLUSION: RLHN is a feasible and safe technique for the experienced paediatric laparoscopic urologist. Results compare very favourably with open heminephrectomy in terms of operating time and outcomes. Long-term follow up is mandatory.