Current trends and prospects of surgical techniques for hepatoblastoma.

Hepatoblastoma, a common extracranial malignant solid tumor in childhood, is often detected at an advanced stage and is difficult to treat surgically. Despite the availability of multiple comprehensive treatments that can be combined with surgery, hepatoblastoma treatment outcomes remain poor. Surgery is the main treatment strategy for hepatoblastoma, but it faces many challenges, including tumor attachment to surrounding tissues, tumor wrapping or invading of vital organs and tissues, the presence of giant or multiple tumors, distant metastasis, the formation of a tumor thrombus, and significant surgical trauma. In this review, we discuss recent research advances and propose potential strategies for overcoming these challenges. Such strategies may improve the rate of hepatoblastoma resection and local control in children, as well as reduce complications and trauma.

Comparison of robotic versus thoracoscopic repair for congenital esophageal atresia: a propensity score matching analysis.

BACKGROUND: Despite the rapid advancement of robotic surgery across various surgical domains, only cases of robotic repair (RR) for neonates with esophageal atresia (EA) have been reported. Comprehensive studies comparing RR and thoracoscopic repair (TR) are lacking. The authors aimed to compare the safety and efficacy of RR and TR for EA. METHODS: A retrospective multicenter study was conducted on 155 EA neonates undergoing RR (79 patients) or TR (76 patients) between August 2020 and February 2023 using propensity score matching. Asymmetric port distribution and step-trocar insertion techniques were applied during RR. Demographics and surgical outcomes were compared. RESULTS: After matching, 63 patients (out of 79) in RR group and 63 patients (out of 76) in TR group were included. There were no significant differences in short-term outcomes between two groups, except for longer total operative time (173.81 vs. 160.54 min; P <0.001) and shorter anastomotic time (29.52 vs. 40.21 min; P <0.001) in RR group. Compared with TR group, the RR group had older age at surgery (8.00 vs. 3.00 days; P <0.001), but a comparable pneumonia rate. More importantly, the incidence of anastomotic leakage (4.76 vs. 19.05%, P =0.013), anastomotic stricture (15.87 vs. 31.74%, P =0.036) within 1 year postoperatively, and unplanned readmission (32.26 vs. 60.00%, P =0.030) within 2 years postoperatively were lower in RR group than in TR group. CONCLUSIONS: RR is a technically safe and effective option for EA patients. This approach delays the age of surgery without increasing respiratory complication rates while reducing the incidence of postoperative anastomotic complications and unplanned readmission.

Robotic-Assisted Proctosigmoidectomy vs. Laparoscopic-Assisted Soave Pull-Through for Hirschsprung's Disease: Medium-Term Outcomes From a Prospective Multicenter Study.

OBJECTIVE: To compare the surgical outcomes of robotic-assisted proctosigmoidectomy (RAP) and laparoscopic-assisted Soave pull-through (LAP) for children with Hirschsprung's disease (HD). SUMMARY BACKGROUND DATA: LAP and RAP have been developed for minimally invasive pull-through of HD, but the clinical benefits of robotic-assisted versus laparoscopic-assisted approaches have yet to be proven in a multicenter prospective study. METHODS: This study was a prospective multicenter clinical trial conducted on children with rectosigmoid/descending HD from July 2015 to June 2022, with registration in the Chinese Clinical Trial Registry (ChiCTR2000035220). The primary outcome was the medium-term functional outcomes in children aged ≥4 years based on bowel functional scores, which were assessed and compared between LAP and RAP. RESULTS: A total of 328 consecutive patients (RAP=165, LAP=163) were approached who were considered eligible for elective minimally invasive endorectal pull-through, and 219 patients aged ≥4 years of age completed follow-up (RAP=109, LAP=110). The transanal dissection length and anal traction time were significantly shorter in RAP than those in LAP (0.30 cm vs. 3.70 cm, P <0.001; 45 min vs. 62 min, P <0.001). The RAP group had significantly lower urinary retention rate (0% vs. 5.52%, P=0.006), while other short-term results between two groups were not significantly different. The medium-term overall BFS scores were comparable between two groups; however, among the subgroup of children aged ≤ 3 months at surgery, the RAP group had better anal canal resting pressure at one year postoperatively and amounted to better annual POFC scores at 4-7 years old postoperatively (all P <0.05). CONCLUSIONS: RAP and LAP should have similar medium-term bowel functional outcomes in HD children, but RAP may be associated with a slight functional benefit in infants operated on below age 3 months, requiring further investigation in larger case cohorts.

Robotic-assisted proctosigmoidectomy for Hirschsprung's disease: A multicenter prospective study.

BACKGROUND: Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung's disease (HSCR). AIM: To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients. METHODS: From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed. RESULTS: No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo. CONCLUSION: RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.

Validation and effect of the NASA-TLX score on the assessment of the workload of pediatric robotic operations.

OBJECTIVE: The objective of the study was to assess the validity of the NASA-TLX score in rating the workload of pediatric robotic operations. METHODS: The workload of 230 pediatric gastrointestinal and thoracic robotic operations was rated using the NASA-TLX score. The difference between the high workload group and the low workload group in each subscale of the NASA-TLX score was analyzed. The correlation of each subscale with the total workload score in the high workload group and low workload group was also analyzed. A logistic regression analysis was subsequently conducted to assess the effects of different factors (sex, age, weight, procedure duration, procedure specialties, combined malformation and blood loss) on the workload. RESULTS: The average NASA-TLX score was 56.5 ± 5.1 for the total group, 56.9 ± 5.0 for the gastrointestinal group and 54.6 ± 4.8 for the thoracic group, p = 0.007. The score of the high workload group was 62.7 ± 3.2, while it was 50.6 ± 2.7 for the low workload group (p < 0.001). The score on each subscale was also significantly different between the high and low workload groups. In the high workload group, a stronger correlation was observed between the total score and TD and Fr and a lower correlation with MD and Pe. In the low workload group, all six subscales showed a moderate correlation with the total score. A multivariate logistic regression analysis revealed that the procedure duration was an independent influencing factor for a higher workload score. CONCLUSIONS: NASA-TLX is a valid tool to rate the surgeon's workload in pediatric robotic surgery. A longer operative time contributes to a higher workload.

Robotic-assisted Kasai portoenterostomy for biliary atresia.

BACKGROUND: Robotic-assisted Kasai portoenterostomy (RAKPE) has been utilized to treat biliary atresia (BA). However, RAKPE is not widely performed and its efficacy remains unknown. We summarized the experience of RAKPE for BA and determined its efficacy. MATERIALS AND METHODS: We retrospectively analyzed 25 consecutive infants with non-syndromic type III BA who received RAKPE in our center from January 2020 to July 2021. RAKPE is a three-arm setup and four-trocar operation. Bipolar coagulation was used to dissect the small blood vessels at the hepatic portal. The fibrous cone was shallowly transected with bending electric scissors, followed by gelatin sponge compression to staunch the hemorrhage. Finally, a wide anastomosis was accurately constructed. Demographics and outcomes were recorded. RESULTS: The mean operative time was 211.64 ± 18.93 min. No conversion to laparotomy or intraoperative complications occurred. The mean estimated blood loss was 7.64 ± 2.43 mL. Enteral feeding was resumed after 3.44 ± 1.23 days. All patients achieved bile excretion postoperatively, and dark green bile-stained stools were passed 1.50 days (range 1.00-3.00 days) after surgery. The average postoperative length of hospital stay was 10.32 ± 2.59 days. The jaundice clearance (JC) rate was 76.00% within 6 months after surgery and the incidence of cholangitis was 48.00% within 1 year following surgery. The survival with native liver (SNL) rate was 80.00% at 1 year and 66.67% at 2 years. CONCLUSION: RAKPE can be regarded as a treatment option for patients with BA due to the good outcomes reported. However, long-term studies comparing open or laparoscopic approaches are needed.

Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis.

BACKGROUND: Most commonly, cyst excision and Roux-en-Y hepaticojejunostomy reconstruction are the optimal treatment for choledochal cysts (CC). Robotic surgery (RS) is being conducted with increasing frequency to treat CC. It is unclear whether RS can overcome the limitations of laparoscopic surgery (LS) and improve the prognosis of patients. In terms of efficacy, evidence concerning which minimally invasive surgery is preferred is, however, sparse. Our objective is to further compare the efficacy of RS and LS in children with CC and draw a useful clinical conclusion. METHODS: Studies meeting inclusion criteria were identified from a series of databases, consisting of PubMed, Embase, Scopus, Web of Science, the Cochrane Library and their reference list of articles up to May 2022. Eligible articles comprised at least five objects that were younger than 18 years of age and the language was limited to English. Two authors independently evaluated selected studies and extracted data for analysis. RESULTS: Forty studies were selected for analysis, with thirty-six reporting data on LS and eight containing data on RS. The pooled conversion rate and pooled postoperative complication rate of RS were lower than those of LS, but none of them was statistically significant. Moreover, comparisons of the following detailed postoperative complication rates were not statistically significant, such as intestinal obstruction or ileus, anastomotic bleeding, anastomotic or bile leakage, and anastomotic stenosis. However, the intraoperative blood loss and the postoperative hospital stay in RS group were significantly lower than those in LS group. CONCLUSIONS: RS is a safe and feasible option for children with CC. Further studies with more cases, long-term efficacy and health economics analysis are needed to confirm whether RS is more advantageous.

Sternum length norms in Han youngsters in central China.

The sternum is one of the most important components of the chest wall. However, to the best of our knowledge, at present there is no reference value of the sternum length in normal Han Chinese children that has been published in the literature. The aim of the present study was therefore to establish the reference value of sternum length in a normal Han Chinese population of different ages and sex groups. Chest computed tomography scans and three-dimensional reconstruction images of 1,080 individuals who were younger than 18 years old and without congenital or acquired structural anomalies or congenital metabolic diseases were retrospectively reviewed. The length of the sternum was measured for each individual and comparisons of the sternum length according to sex were conducted using the Mann-Whitney test. Age or region group comparisons were performed using the ANOVA test, and the association between the length of the sternum and age was assessed by regression analysis. A significant association between the age (x) of the individual and the length of the sternum (y) was confirmed, although different regression patterns were identified for the sexes (the regression equation for males was y=5.616x+60.408; P<0.001; R2=0.890, whereas that for females was y=-0.134x2+6.543x+56.805; P<0.001, R2=0.890). No significant differences in sternum length were identified between the sexes for subjects aged 1-13 years old, whereas significant differences were observed comparing the sexes of the subjects aged 14-18 years old. In conclusion, the present study revealed that the length of the sternum in normal Han Chinese children can be precisely estimated by the age of the child using our formulae for the different sexes (where the most-fit formulae for the two sexes are different). This knowledge can be applied clinically in chest wall deformity assessment, and in surgery planning.

Maternal regulation of biliary disease in neonates via gut microbial metabolites.

Maternal seeding of the microbiome in neonates promotes a long-lasting biological footprint, but how it impacts disease susceptibility in early life remains unknown. We hypothesized that feeding butyrate to pregnant mice influences the newborn's susceptibility to biliary atresia, a severe cholangiopathy of neonates. Here, we show that butyrate administration to mothers renders newborn mice resistant to inflammation and injury of bile ducts and improves survival. The prevention of hepatic immune cell activation and survival trait is linked to fecal signatures of Bacteroidetes and Clostridia and increases glutamate/glutamine and hypoxanthine in stool metabolites of newborn mice. In human neonates with biliary atresia, the fecal microbiome signature of these bacteria is under-represented, with suppression of glutamate/glutamine and increased hypoxanthine pathways. The direct administration of butyrate or glutamine to newborn mice attenuates the disease phenotype, but only glutamine renders bile duct epithelial cells resistant to cytotoxicity by natural killer cells. Thus, maternal intake of butyrate influences the fecal microbial population and metabolites in newborn mice and the phenotypic expression of experimental biliary atresia, with glutamine promoting survival of bile duct epithelial cells.

Feasible techniques in robotic thoracoscopic repair of congenital esophageal atresia: case report and literature review.

Background: Robotic repair for esophageal atresia (EA) using da Vinci system is challenging. Specific surgical techniques need to be explored to overcome the current hurdles. Case presentation: Two cases with EA (type I and type III by Gross classification, respectively) were repaired using da Vinci robotic system. Step trocar insertion and asymmetric ports distribution techniques were used. The mean weight was 3.2 kg. Operative times were 95 min totally, with the anastomotic time of 27.5 min. Follow-up duration was 12 months. Esophageal fistula reoccurred in one case. None was confirmed anastomotic stricture. Conclusion: Step trocar insertion procedure and asymmetric ports distribution technique are effective in robotic esophageal atresia.

Outcomes in robotic versus laparoscopic-assisted choledochal cyst excision and hepaticojejunostomy in children.

BACKGROUND: Robotic-assisted surgery (RAS) is becoming more popular because of the excellent performance in anastomosis and knot tying, especially in complex surgical procedures such as hepaticojejunostomy. As for operative time and costs, laparoscopic-assisted surgery (LAS) seem to be more advantageous. To date, there are only limited studies focusing on the comparison between RAS and LAS. This study aims to investigate differences in intraoperative and postoperative outcomes between robotic and laparoscopic approaches. METHODS: We performed a retrospective case-control study of 140 patients operated via mini-invasive approaches for choledochal cyst (CC) excision and hepaticojejunostomy at the Wuhan Union Hospital from Jun 2014 to Dec 2019. A multivariable logistic regression model for odds to having complications was built. RESULTS: The two groups were similar in age, sex, follow-up time, and Todani modification of the Alonso-Lej classification distribution. Patients undergoing RAS had longer overall operative time, shorter cyst excision time, shorter hepaticojejunostomy time, less estimated blood loss, a smaller postoperative high fever rate, shorter postoperative LOS, and a lower postoperative complication rate. Moreover, the intraoperative anatomy structures were more explicit in group RAS, such as the exposure of left or right hepatic duct opening and intrapancreatic bile duct. Multivariable logistic regression showed that longer hepaticojejunostomy time was the only risk factor of postoperative complications. CONCLUSION: Robotic-assisted CC excision and hepaticojejunostomy was associated with better intraoperative and short-term postoperative outcomes when compared to laparoscopic-assisted surgery.

Resuturing Without Enterostomy for the Treatment of Early-Stage Anastomotic Leaks After Laparoscopic Soave Procedure in Hirschsprung's Disease.

Background: Anastomotic leak (AL) rates gradually decreased with surgical skills and perioperative management progression, but it is still inevitable. As the traditional management of AL after the pull-through procedure of Hirschsprung's disease (HD), enterostomy could lead to multiple surgeries, repeated hospitalizations, increased costs, and enterostomy-associated complications. This study aimed to explore the safety and feasibility of resuturing without enterostomy treating early AL after the laparoscopic Soave procedure. Methods: From October 2014 to June 2019, 10 patients who had AL after the laparoscopic Soave procedure were included. Six patients underwent simply resuturing with presacral drainage; the reoperation time was 1-5 days after primary surgery. Four patients who had diffused peritonitis or severe inflammations received resuturing with an ileostomy, and the reoperation time was 6-11 days. Results: Common early symptoms of AL included persistent fever, sacrococcygeal pain, and abdominal pain. The median delay to reoperation was 1.0 (0-2.25) day. Five patients had leaks at the 3-6 o'clock position, two had leaks at the 6-9 o'clock, and the other three had leaks at the 6 o'clock. The median postoperative fever durations were similar in patients without or with an ileostomy, and the median length of intensive care unit (ICU) stays, duration of antibiotic use, and postoperative length of stay were significantly longer in patients with ileostomy. The mean follow-up time was 38.5 ± 16.7 months (15-69 m). As of the time of writing, no reoccurrence was identified. Conclusion: For patients without diffuse peritonitis, severe inflammations, early diagnosis and timely resuturing of AL within 5 days after the laparoscopic Soave procedure of HD could be a safe, effective, and pleasing treatment.

Haematological and immunological data of Chinese children infected with coronavirus disease 2019.

Haematological and immunological data of children with COVID-19 infection is lacking. Between 21st January and 20th March 2020, 244 children who were confirmed to have COVID-19 infection and admitted to the Wuhan Children's Hospital, China were retrospectively reviewed. 193 children were considered as symptomatic, which was defined as having either the presence of clinical symptoms or the presence of CT thorax abnormalities. Their haematological and immunological profiles, including complete blood counts, lymphocyte subsets (T, B and NK cell counts), immunoglobulin (Ig) profiles (IgG, IgA and IgM) and cytokine profiles were analysed and compared between the symptomatic and asymptomatic groups. The median values and the interquartile ranges were calculated. Comparison was made using the Mann-Whitney U test. Children with symptomatic COVID-19 infection had significantly lower haemoglobin levels, but higher absolute lymphocyte and monocyte counts, IgG and IgA levels, as well as interleukin 6 (IL-6), IL-10, tumour necrosis factor alpha and interferon gamma levels. The obtained data will be utilized for further studies in comparing children and adults with COVID-19 infections in other parts of the world and with different severity .

Robot-assisted thoracoscopic plication for diaphragmatic eventration.

BACKGROUND: Though conventional thoracoscopic plication is a favorable option of diaphragmatic eventration (DE), ribs limited the movement of trocars, making it difficult to suturing, knot-tying and time-consuming. The purpose of this study was to evaluate delicate surgical maneuvers and suturing time for the management of DE in robot-assisted thoracoscopic plication (RATP). METHODS: From January 2015 to November 2019, 20 patients (14 males; mean age: 10.5 ±â€¯5.2 months; mean weight: 8.6 ±â€¯4.5 kg) who underwent diaphragmatic plication for DE were reviewed at our institution. There were 13 patients with congenital diaphragmatic eventration and 7 patients with acquired diaphragm eventration after congenital heart surgery. RATP was performed on 9 patients (3 on the left and 6 on the right), and conventional thoracoscopic plication (CTP) was applied to 11 patients (5 on the left and 6 on the right). Demographics, the suturing time and complications were respectively evaluated. RESULTS: There was no difference between 2 groups with respect to gender, age at surgery and weight (p > 0.05). No conversion to thoracotomy was needed. The suturing time in RATP group was shorter than CTP group (27.7 ±â€¯3.4 min vs 48.1 ±â€¯4.2 min, p < 0.001). One patient (9.09%) experienced recurrence in CTP group and none was found in RATP group. CONCLUSIONS: Diaphragmatic plication with robot-assisted thoracoscopy or conventional thoracoscopy in DE has minimally invasive and good effect on children. RATP overcome the intercostal limitations to complete delicate suturing and free knot-tying, and has better ergonomics. LEVEL OF EVIDENCE: Level III.

Primary laparoscopic endorectal pull-through procedure with or without a postoperative rectal tube for hirschsprung disease: a multicenter perspective study.

BACKGROUND: Hirschsprung-associated enterocolitis (HAEC) is a significant complication of HD both in the pre- and postoperative periods. This was a large multicenter series study to determine the effect of preserving a postoperative rectal tube on preventing HAEC after primary laparoscopic endorectal pull-through procedure. METHODS: Between 2014 and 2017, a total of 383 consecutive patients with rectosigmoid segment HD were randomly divided into group A (n = 190) and group B (n = 193). All of them underwent primary laparoscopic pull-through procedure, with the same postoperative treatment protocols except for group A with a rectal tube after surgery for 5 days, while group B did not have it. The mean time of follow-up was 2.0 ±â€¯0.53 years (0.5-3.6 years). Demographics, operative data, postoperative complications, and clinical outcomes were compared between these two groups. RESULTS: Outcomes within 1 month after surgery indicated a lower incidence of abdominal distention (4% vs 15.5%, P < 0.05) and postoperative HAEC (1.2% vs 6.8%, P < 0.05) in group A compared to group B. Beyond 1 month after surgery, the overall incidence of HAEC was not significantly different (12% vs 13.1%, P = 0.54). However, further analysis revealed that the patients who suffered HAEC twice or above twice in group A were significantly less than those in group B (3.6% vs 8.3%, p = 0.02). There were no significant differences in the defecation frequency and other complications. CONCLUSIONS: Primary laparoscopic endorectal pull-through procedure with a postoperative rectal tube can reduce the early-stage postoperative incidence of abdominal distension and HAEC and the risk of HAEC recurrence in the long term, and is beneficial to postoperative management. LEVEL OF EVIDENCE: Level 2.

Transumbilical enterostomy for Hirschsprung's disease with a two-stage laparoscopy-assisted pull-through procedure.

BACKGROUND: A one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease (HD) due to its superior cosmetic results. One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications. However, enterostomy is required in some HD cases for enterocolitis and dilated colon. Our transumbilical enterostomy (TUE) and two-stage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation, but the effect in patients with HD is unclear. AIM: To evaluate the safety, efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD. METHODS: From June 2013 to June 2018, 53 patients (40 boys, 13 girls; mean age at enterostomy: 5.5 ± 2.2 mo) who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution. Two enterostomy approaches were used: TUE in 24 patients, and conventional abdominal enterostomy (CAE) in 29 patients. Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon. 26 patients had long-segment HD, and 16 patients had total colonic aganglionosis (TCA). The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure, and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure. Demographics, enterostomy operative time, complications and cosmetic results were respectively evaluated. RESULTS: There were no differences between the groups with respect to gender, age at enterostomy, weight and clinical type (P > 0.05). No conversion to open technique was required. Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group (8.33% vs 3.45%, P > 0.05). No parastomal hernia was observed in either of the two groups. Wound infection at the stoma was seen in 1 case in the TUE group, and 2 cases in the CAE group (4.17% vs 6.90%, P > 0.05). No obstruction was noted in any of the patients in the TUE group, whereas obstruction was found in 1 patient in the CAE group. Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group, respectively (12.50% vs 17.24%, P > 0.05). There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation (P > 0.05). The cosmetic result using the scar score in the TUE group was better than that in the CAE group (6.83 ± 0.96 vs 13.32 ± 1.57, P < 0.05). CONCLUSION: TUE is a safe and feasible method for the treatment of HD, and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.

Two-Staged Versus Three-Staged Laparoscopic Anorectoplasty for Patients with Rectoprostatic and Bladder Neck Fistulas: A Comparative Study.

Purpose: To compare the results of two- versus three-staged laparoscopic anorectoplasty (LARP) in children with rectoprostatic and bladder neck fistulas. Materials and Methods: The present study was retrospectively initiated among 32 consecutive patients who underwent two-staged LARP from October 2010 to December 2012. The associated defects, age at the operation, operative time, complications, length of the postoperative hospital stay, total hospitalization cost, and functional results (according to the Krickenbeck scoring system) were evaluated. The results were compared with those of 19 cases who underwent three-staged LARP from October 2008 to September 2010. Results: The average age at the second operation was 4.5 ± 1.2 months in the two-staged group, and 4.2 ± 1.3 months in the three-staged group. In the two-staged group, there were statistically shorter overall operative time and postoperative hospital stay duration. Also, a significantly lower total hospitalization cost was achieved. There was no anastomotic leak in either group. The rates of perineal wound infection, recurrent fistula, and rectal prolapse were 3.85% versus 0% (P = 1.000), 0% versus 5.3% (P = .422), and 11.5% versus 15.8% (P = .686), respectively (two-staged versus three-staged group). The median follow-up time was 67 (range, 54-80) months and 88 (range, 81-104) months, respectively. No significant difference in functional outcome was observed. Conclusions: Two-staged LARP is feasible, safe, and more cost-effective, with comparable incidences of complications and functional outcomes with respect to a three-staged procedure.

Diagnosis of Hirschsprung's Disease by Immunostaining Rectal Suction Biopsies for Calretinin, S100 Protein and Protein Gene Product 9.5.

Hirschsprung's disease (HD) is a congenital intestinal disease that is clinically manifested as an inability to pass meconium in infants or as long-term constipation in children. Rectal suction biopsy (RSB) to determine the absence of ganglion cells and neural hypertrophy is the most accurate test for the diagnosis of HD at present. Traditional hematoxylin-eosin staining lacks sensitivity and specificity. Acetylcholinesterase staining cannot be widely used due to its complex process. Our novel protocol of immunostaining for calretinin, S100 protein, and protein gene product 9.5 (PGP9.5), which we conducted on RSBs, exhibits high sensitivity and specificity rates of 96.49% (95% confidence interval, 0.88-0.99) and 100% (95% confidence interval, 0.97-1.00), respectively. The HD-affected segments often present as the absence of the expression of calretinin, S100 protein, and PGP9.5, which are markers of neural hypertrophy in the submucosal tissue. This protocol describes the detailed operating process of this new diagnostic method.

Laparoscopic-assisted cyst excision and ductoplasty plus widened portoenterostomy for choledochal cysts with a narrow portal bile duct.

BACKGROUND: Complete cyst excision with Roux-en-Y hepaticojejunostomy is the standard procedure for choledochal cysts (CCs). In recent years, neonates have been increasingly diagnosed with CCs prenatally. Earlier treatment has been recommended to avoid complications. For type IVa malformation without extensive intrahepatic bile duct dilatation, laparoscopic hepaticojejunostomy is technically challenging, and anastomotic stricture is a concern. Therefore, we propose laparoscopic synthetical techniques-laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy to avoid stricture in CCs with a narrow hilar duct. METHODS: An anastomosis was created around the transected end of the common bile duct in 12 minipigs (Group A), and another 12 minipigs (Group B) received conventional cholangiojejunostomy. Anastomotic diameter measurements and cholangiography were conducted at different times. Histological findings of inflammation and scarring were compared. The expression levels of TGF-ß1 and type I collagen were detected by real-time quantitative PCR. Between January 2012 and January 2016, laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy were performed on 29 children with confirmed CCs with a narrow portal bile duct who were followed up for 12-48 months. RESULTS: Group A survived well without obstruction. Slight inflammation and fibrotic tissue were confined to the bile duct periphery. In Group B, five pigs developed stricture. Severe inflammation and diffuse fibrosis affected the whole layer of the anastomosis. Fibrotic biomarkers were significantly higher postoperatively in Group B. Clinically, 29 patients exhibited satisfactory outcomes. No anastomotic stricture has been observed to date. CONCLUSIONS: Laparoscopic synthetical techniques may be a superior option to prevent anastomotic stricture in treating CCs with a narrow portal bile duct.