Impact of Helicobacter pylori infection on fluid duodenal microbial community structure and microbial metabolic pathways.

BACKGROUND: The bioactivities of commensal duodenal microbiota greatly influence the biofunction of hosts. We investigated the role of Helicobacter pylori infection in extra-gastroduodenal diseases by determining the impact of H. pylori infection on the duodenal microbiota. We sequenced 16 S rRNA genes in samples aspirated from the descending duodenum of 47 (male, 20; female, 27) individuals who were screened for gastric cancer. Samples were analysed using 16 S rRNA gene amplicon sequencing, and the LEFSe and Kyoto Encyclopaedia of Genes and Genomes methods were used to determine whether the duodenal microflora and microbial biofunctions were affected using H. pylori infection. RESULTS: Thirteen and 34 participants tested positive and negative for H. pylori, respectively. We identified 1,404 bacterial operational taxonomic units from 23 phyla and 253 genera. H. pylori infection changed the relative mean abundance of three phyla (Proteobacteria, Actinobacteria, and TM7) and ten genera (Neisseria, Rothia, TM7-3, Leptotrichia, Lachnospiraceae, Megasphaera, F16, Moryella, Filifactor, and Paludibacter). Microbiota features were significantly influenced in H. pylori-positive participants by 12 taxa mostly classified as Gammaproteobacteria. Microbial functional annotation revealed that H. pylori significantly affected 12 microbial metabolic pathways. CONCLUSIONS: H. pylori disrupted normal bacterial communities in the duodenum and changed the biofunctions of commensal microbiota primarily by upregulating specific metabolic pathways. Such upregulation may be involved in the onset of diseases associated with H. pylori infection.

Patchy innervation confirmed in pull-through bowel with normal conventional biopsy results in Hirschsprung's disease - the benefit of circumferential biopsying.

The effectiveness of pull-through for Hirschsprung's disease is dependent on accurate identification of normoganglionic bowel in intraoperative biopsy specimens. We report 2 cases of patchy innervation of pull-through bowel in children with Hirschsprung's disease only identified by circumferential biopsying. Case 1 was an 8-month-old boy. During laparoscopy-assisted transanal endorectal pull-through, extra biopsies of bowel were taken circumferentially, 2 cm proximal to the level of normoganglionosis confirmed by laparoscopic colon biopsies. Aganglionosis was found at 3 o'clock, suggesting that bowel innervation at this level was patchy. Circumferential biopsies were performed a further 2cm proximally, and all sites were normoganglionic. This level was used for pull-through with excellent outcome. Case 2 was a 27-day-old boy. Similarly, extra biopsies were taken circumferentially, 2cm proximal to the level of "normoganglionosis" as indicated by conventional biopsying. Normoganglionosis was found only at 3 o'clock, while all other sites were hypoganglionic. A further series of circumferential biopsies was performed 2 cm proximally and hypoganglionosis was still identified, but only at 6 o'clock. Circumferential biopsies were repeated another 2cm proximally, and all sites were normoganglionic. We recommend circumferential biopsies be performed routinely to prevent bowel with patchy innervation from being used for pull-through and possibly causing postoperative bowel dysmotility in a subgroup of Hirschsprung's disease patients.

Anorectal neural crest derived cell behavior after the migration of vagal neural crest derived cells is surgically disrupted: implications for the etiology of Hirschsprung's disease.

BACKGROUND/PURPOSE: In Hirschsprung's disease (HD), thick extrinsic nerve fibers can be associated with the aganglionic segment in the anorectum. We surgically disrupted the migration of vagal neural crest cell-derived cells (vagal NCC) in embryos from transgenic mice we created previously (SOX10-VENUS Tg) which have the SOX10 gene labeled with Venus (V), a green fluorescent protein, to observe sacral NCC activity in the anorectum. METHOD: Proximal colon harvested from SOX10-VENUS Tg embryos on day 10.5 (n = 10) was transected at the ascending colon. V-positive sacral NCC in the anorectum were observed during organ culture under fluorescence stereoscopic microscopy, and compared with non-transected control specimens (n = 10). RESULTS: In transected specimens, no V-positive sacral NCC were identified initially in the anorectum. By day 2, there were thick beaded sacral NCC in the anorectum in 6/10 (60 %) that migrated steadily to the transected end over 3-4 days. In controls, thinner and shorter V-positive sacral NCC began migrating cranially on day 2, and were met by distally migrating vagal NCC. CONCLUSION: Disruption of vagal NCC migration appears to induce sacral NCC activity in the anorectum, suggesting that thick extrinsic nerve fibers seen in HD may be a secondary phenomenon.

Elevation in white blood cell count and development of hyper LDL cholesterolemia.

To investigate the relationship between white blood cell (WBC) count and incidence of hyper-low-density lipoprotein (LDL) cholesterolemia in a population-based longitudinal study. This is a retrospective study using data of annual health check-ups for residents of Iki City, Japan. A total of 3312 residents (≥ 30 years) without hyper-LDL cholesterolemia at baseline were included in this analysis. Primary outcome was incidence of hyper-LDL cholesterolemia (LDL cholesterol levels ≥ 3.62 mmol/L and/or use of lipid lowering drugs). During follow-up (average 4.6 years), 698 participants development of hyper-LDL cholesterolemia (incidence 46.8 per 1000 person-years). Higher incidence of hyper-LDL cholesterolemia was observed among participants with higher leukocyte count (1st quartile group: 38.5, 2nd quartile group: 47.7, 3rd quartile group: 47.3, and 4th quartile group: 52.4 per 1,000 person-years, P = 0.012 for trend). Statistically significant relation was observed even after adjustment for age, gender, smoking, alcohol intake, leisure-time exercise, obesity, hypertension and diabetes: hazard ratio 1.24 (95% confidence interval 0.99 to 1.54) for 2nd quartile group, 1.29 (1.03-1.62) for 3rd quartile group and 1.39 (1.10-1.75) for 4th quartile group, compared with 1st quartile group (P for trend = 0.006). Increased WBC count was related to incidence of hyper-LDL cholesterolemia in general Japanese population.

Fecal and urinary continence after scope-assisted anorectovaginoplasty for female anorectal malformation.

AIM: We assessed continence after scope-assisted anorectovaginoplasty (SARVP) for female anorectal malformation (FARM). METHODS: Five FARM cases were assessed; cases 1 and 2: cloacal malformation; case 3: urogenital sinus, and rectovestibular fistula (RF); case 4: RF, absent vagina, and sacral anomaly; case 5: covered cloacal exstrophy. Treatment was SARVP in all cases, with perineal vaginoplasty (case 1), vagina pull-through (PT) similar to Georgeson's colon PT (case 2), and the use of the native RF/cloaca channel as a vagina (cases 3-5). Continence was assessed pre and postoperatively. RESULTS: SARVP was performed in the lithotomy position without repositioning. Mean age at surgery was 3.2 (1.7-5.5) years. Current mean age: 8.8 years (range 7.5-12.2). Mean follow-up: 5.7 years. Preoperative continence: fecal: all had stomas; urinary: cases 1 and 2: continent; cases 3-5: incontinent. Postoperative continence: fecal: cases 1-3: continent; case 4: incontinent; case 5: awaiting stoma closure; urinary: cases 1 and 2: continent; cases 3 and 4: incontinent; case 5: continent (intermittent catheterization). Fetal continence evaluation questionnaire (CEQ) scores for cases 1-4 were 7.5, 9, 10, and 2 (maximum score 10, mean 7.1). CONCLUSION: Scope assistance improves visualization, thus pelvic sphincter dissection/division is minimized with less detrimental impact on postoperative continence.

Reappraising the portoenterostomy procedure according to sound physiologic/anatomic principles enhances postoperative jaundice clearance in biliary atresia.

BACKGROUND: The portoenterostomy (PE) procedure for treating biliary atresia (BA) has been so repeatedly modified that it currently hardly resembles Kasai's original PE (KOPE). Now PE involves an extended lateral dissection and a wide anastomosis (extended PE: EPE). We reappraised KOPE and created our-KOPE (OKOPE) by adhering strictly to its principles and techniques. We compared outcome of EPE and OKOPE. METHODS: We reviewed 24 consecutive cases of PE for BA performed at our institution from 2005 to 2011. Thirteen had EPE, and 11 had OKOPE. Body weight, serum total bilirubin, age at PE, total steroid dosage required for jaundice clearance (JC: total bilirubin ≤1.2 mg/dL), JC ratio, time taken for JC, survival rate with the native liver (SNL), and SNL after JC (SNL + JC) were compared at 16 months (shortest mean follow-up). Postoperative management protocols were identical for both groups. RESULTS: The JC ratio was significantly higher for OKOPE (90.9%) than EPE (46.2%) (p = 0.02). Both SNL and SNL + JC were significantly higher for OKOPE (90.9 and 72.7%) than EPE (30.8 and 30.8%) (p = 0.003 and p = 0.04, respectively). All other variables were similar for both groups. CONCLUSIONS: Jaundice clearance following OKOPE would appear to be better than after EPE.

Acute Myocarditis with Severe Fever and Thrombocytopenia Syndrome.

A 67-year-old man, hospitalized with fever and pancytopenia, experienced cardiogenic shock on the 3rd day of hospitalization. He complained of chest pain and exhibited cardiac dysfunction, upregulated serum troponin levels, and an ST elevation on electrocardiogram. Severe fever with thrombocytopenia syndrome (SFTS) was suspected based on the symptom course after a tick bite and was definitively diagnosed using the serum polymerase chain reaction (PCR) test. An endomyocardial biopsy performed in the convalescent phase revealed a sign of myocardial inflammation with increases in CD3- and CD68-positive cells. We herein report the first case of acute myocarditis complicated with SFTS.

Choledochal cyst and systemic lupus erythematosus.

A 16-year-old female with systemic lupus erythematosus was diagnosed with choledochal cyst. As high-dose steroids had been prescribed for CNS lupus, surgery was performed under steroid cover. Despite postoperative pneumonia and wound infection, she is well 2 years later. There is no similar report in the literature.

Intralaparoscopic endoscopy: its value during laparoscopic repair of choledochal cyst.

AIM: We report our experience of laparoscopic repair of choledochal cyst (CC). METHODS: We reviewed 10 CC patients (mean age 3.3 years) who had lap CC repair. Eight patients had minimally dilated/fusiform type CC (fusiform CC) and presented with pancreatitis, and two had cystic type CC (cystic CC). Using conventional trocar placement (right upper quadrant, left paraumbilical, left upper quadrant; laparoscope in the umbilicus), the CC was isolated and transected at mid level. An additional 3.9 mm trocar in the left epigastrium was used to introduce a fine ureteroscope. Its tip was inserted into the common channel through the distal CC to remove protein plugs (PP) under laparoscopic guidance. To perform intralaparoscopic endoscopy of the intrahepatic ducts, a trocar placed in the left lower quadrant was used. Two extra trocars (3 and 5 mm) were added for hepatico-jejunostomy anastomosis (HJA); one lateral right subcostal, and one between the right subcostal and right upper quadrant trocars, respectively. HJA was performed using interrupted 5/0 absorbable sutures with the right upper quadrant trocar as a needle holder in the right hand, 5 mm for the laparoscope, and 3 mm subcostal trocar as a needle receiver in the left hand. Both the right and left edge sutures were exteriorized and used as traction sutures during anastomosis of the anterior wall. RESULTS: Seven of eight fusiform CC patients had PP (massive in 3, moderate in 3, little in 1) in the common channel successfully removed with normal saline washouts through the side channel of the ureteroscope. Eight of ten CC patients had debris (moderate in 4, little in 4) in the intrahepatic ducts. Two complications were encountered; pancreatitis that resolved with conservative management and duodenal obstruction due to inadequate Roux-en-Y limb fixation that was treated by laparoscopic intervention. All are well after a mean follow-up of 12 months with cosmetically attractive wounds. CONCLUSION: Although three additional trocars are required, we recommend our HJA technique and intraoperative common channel endoscopy during laparoscopic repair of CC.

Effects of Weight Gain after 20 Years of Age and Incidence of Hyper-Low-Density Lipoprotein Cholesterolemia: The Iki Epidemiological Study of Atherosclerosis and Chronic Kidney Disease (ISSA-CKD).

The aim of this study was to investigate the effects of long-term weight gain from the age of 20 on incidence of hyper-low-density-lipoprotein (LDL) cholesterolemia in the general population of Japanese people. METHODS: We conducted a population-based retrospective cohort study using annual health checkup data for residents of Iki City, Nagasaki Prefecture, Japan. A total of 3179 adult (≥30 years old) men and women without hyper-LDL cholesterolemia at baseline, who underwent two or more health checkups were included in the analysis. Information on weight gain (≥10 kg) after 20 years of age was obtained using questionnaire. The outcome of this study was development of hyper-LDL cholesterolemia defined as LDL-cholesterol level ≥3.62 mmol/L and/or initiation of lipid-lowering medications. RESULTS: During a mean follow-up period of 4.53 years, 665 of the 3179 participants developed hyper-LDL cholesterolemia (46.5/1000 person-years). The incidence of hyper-LDL cholesterolemia was higher in participants with a weight gain of ≥10 kg (55.3/1000 person-years) than among those with a weight gain of <10 kg (41.8/1000 person-years). This association remained statistically significant even after adjustment for age, sex, smoking, daily drinking, exercise, obesity, hypertension, and diabetes (multivariable hazard ratio 1.31, 95% confidence interval 1.08-1.58, p = 0.006). CONCLUSION: A weight gain of ≥10 after 20 years of age affected the development of hyper-LDL cholesterol regardless of age, sex, and obesity in a general population of Japanese.

Anal canal duplication: experience at a single institution and literature review.

PURPOSE: Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. There are not many reports in the English literature, with just a few from each institution. The aim of this study was to describe the clinical characteristics, surgical treatment, and outcome of ACD in pediatric cases at a single institution. METHOD: The medical records of ACD patients we treated from 1988 to 2009 were reviewed retrospectively. RESULTS: There were ten cases, all females. Nine were asymptomatic without any history of perianal infection, identified only incidentally at routine check-up although one case had severe periproctal abscess. Mean age at diagnosis was 6 months (range 0-47 months). Concurrent pathology present were meningocele and presacral mass in one, presacral mass in one, and renal hypoplasia in one. In all cases, an extraneous perianal orifice opening in the midline posterior to the native anus was present, but in one case it was only identified at surgery because it had closed secondary to severe inflammation preoperatively. All had preoperative radiologic investigations, such as magnetic resonance imaging (MRI), barium contrast studies, and fistulography. Mean age at surgery was 14 months (range 1-48 months). All underwent surgical removal of the anal canal duplication, eight through a perineal approach and two through a posterior sagittal approach, depending on the length of the duplicated anal canal and the presence of concurrent anomalies. Histopathology of the excised anal canals showed squamous epithelium in all cases. The postoperative course was uneventful in all cases and all are well without complications at mean follow-up of 9.1 years (range 5-19 years). CONCLUSION: This is the largest series of ACD at a single institution reported to date. For the clinician faced with an extraneous perianal orifice located posteriorly in the midline with respect to the native anus, ACD should be suspected. The treatment of choice in children is complete excision (perineal/posterior sagittal approach), even if asymptomatic. Morbidity is minimal, and outcome is excellent.

Loss of intestine during stoma closure: an experimental model comparing laparoscopic and conventional techniques.

PURPOSE: This study compared laparoscopy-assisted stoma closure (Lap) with conventional closure (Co) to assess loss of intestine. METHODS: Ileostomies (loop L; single S) were performed 5 cm proximal to the ileocecal junction through a right lower quadrant incision in forty 11-week-old Lewis rats (L = 20, S = 20). Stoma closure was performed 60 days later using laparoscopy (Lap) or conventional closure (Co) in 10 rats each, to give 4 groups, Lap-L, Lap-S, Co-L, and Co-S. End-to-end anastomosis was performed through the stoma site in all rats. Bowel resected from the skin to the anastomosis was termed resected unusable bowel (RUB) and measured blindly. Laparotomy was performed 30 days later to assess the status of the anastomosis and complications. RESULTS: Average RUB with Lap was significantly shorter; Lap-L (17.8 mm) versus Co-L (23.8 mm), P = 0.002, and Lap-S (10.6 mm) versus Co-S (13.8 mm), P = 0.001. During Co, accidental full-thickness injury to underlying bowel during stoma take-down occurred in 3 Co-L and 2 Co-S rats. All Lap rats were uncomplicated. Average times taken until end of stoma take-down were 6.1 min for Lap-L (3.2 min for trocar insertion, 2.8 min for stoma take-down), 5.6 min for Lap-S (2.8 and 2.7 min), 6.3 min for Co-L (from first incision to stoma take-down), and 5.1 min for Co-S (P = NS). At laparotomy there was no evidence of complications such as wound infection, incisional hernia or anastomotic stenosis in any rat. CONCLUSIONS: Our results suggest that laparoscopy-assisted stoma closure is safe and quick, and results in less loss of intestine during stoma closure.

Postoperative cystolithiasis in a case of cloacal malformation treated using an endoscopic pneumatic lithotripter through a combination of percutaneous and transurethral approaches.

Long-term management of patients with cloacal malformation is still challenging to pediatric surgeons and urologists. Recently, we experienced postoperative cystolithiasis in a case of cloacal malformation. All stones were removed successfully by using an endoscopic pneumatic lithotripter through a combined approach from the cystostomy and the narrow reconstructed urethra. To the best of our knowledge, this was the first time for this combined approach to be applied in a patient with cloacal malformation. It has a particular appeal because it is simple, safe, and minimally invasive.

Endoscopy-assisted laparoscopic excision of rectourethral fistula in a male with imperforate anus.

We report a surgical technique that we developed to facilitate complete excision of rectourethral fistula (RUF)in male patients with imperforate anus (IA). A 6-month-old boy with rectobulbar urethral fistula (bulbar-RUF)had laparoscopic repair of IA. During laparoscopic dissection of the RUF, a fine flexible endoscope was inserted into the rectum through an opening made in the anterior rectal wall. Endoscopy of the rectum allowed the level of laparoscopic dissection to be observed intraluminally, allowing the bulbar-RUF to be excised exactly at its distal end. He is well after follow-up of 9 months with no evidence of residual RUF on radiologic investigations.We have since used this technique to treat another IA patient with prostatic-RUF successfully.

Spontaneous sutureless closure of the abdominal wall defect in gastroschisis using a commercial wound retractor system.

PURPOSE: We report our experience of using a commercial wound protector and retractor system to allow spontaneous sutureless closure of the abdominal wall defect in gastroschisis. METHODS: Following birth, eviscerated bowel is wrapped with polyethylene wrap, the umbilical cord is deliberately left long and kept moist, and the patient stabilized and transferred to the operating room. Then the Applied Alexis wound protector and retractor system (Applied Medical Resources Corp, USA) was used for reducing eviscerated bowel. Once all organs have been reduced, the wound protector and retractor system (WPAR) is removed and the abdominal wall defect covered with the umbilical cord without suturing. Tegaderm (3M Health Care, USA) is used as a film dressing and is removed once the umbilical cord becomes adhered. RESULTS: We have used this technique to treat seven neonates with gastroschisis between April 2006 and March 2009. In three, WPAR was used as a silo initially, and removed after 3-4 days, and in four, WPAR was used only until primary reduction was achieved and removed. The abdominal defect closed spontaneously in all cases with excellent cosmesis. There were no complications attributed to our technique. At the time of discharge, all patients had insignificant umbilical hernias which have all resolved spontaneously. CONCLUSION: The cosmetic appearance of the abdomen is improved using our technique compared with primary closure involving suturing and a conventional silo.

Immature enteric neurons in Ncx/Hox11L.1 deficient intestinal neuronal dysplasia model mice.

AIM: The Ncx/Hox11L.1 gene is required for adequate development of enteric neurons in mice and Ncx/Hox11L.1 deficient (Ncx-/-) mice are used as a model for human intestinal neuronal dysplasia (IND) because of similar histopathology (hyperganglionosis), however, some 50% of Ncx-/- mice develop megacolon with a caliber change in the proximal colon, and die when 21-35 days old. We used polysialylated neural cell adhesion molecule (PSA-NCAM) to examine the maturity of enteric neurons in Ncx-/- mice to further understand the etiology of IND. METHODS: PSA-NCAM immunoreactivity was measured in specimens taken 1 cm proximal to the ileocecal valve (ileum), 1 cm distal to the ileocecal valve (proximal colon), and 1 cm proximal to the anus (distal colon) from 63 mice (Ncx-/-: n = 14, Ncx+/-: n = 30, and Ncx+/+: n = 19) on days 14 (D14), 21 (D21), and 27 or later (>D27). RESULTS: PSA-NCAM was positive (indicating immaturity) in proximal colon (submucosal and myenteric plexuses) from 8/14 (57%) Ncx-/- mice (2/4 on D14, 4/6 on D21, and 2/4 on >D27) and from 5/30 (17%) Ncx+/- mice (0/2 in D14, 2/13 in D21, and 3/15 in >D27). PSA-NCAM was negative (indicating maturity) in all other specimens. The incidence of PSA-NCAM positive neurons in Ncx-/- appeared to be correlated with the mortality rate seen in IND mice. CONCLUSIONS: Our data suggest that colonic dysmotility and pathology seen in Ncx-/- mice may be due to persistence of immature neurons in the proximal colon, which could also be the case in human IND and warrants further investigation.

Radiographic signs predictive of success of hydrostatic reduction of intussusception.

AIM: Outcome of hydrostatic reduction of intussusception (HRI) was analyzed according to specific radiographic signs to improve success. METHODS: At our institution, a pediatric surgical team performs HRI using a standardized protocol. We reviewed 266 consecutive HRI performed from 1998 to 2008 according to patient demographics, symptomatology, parameters of inflammation (peak WBC, peak CRP), position of the tip of the intussuscepted bowel and an intussusception bowel ratio (IBR). RESULTS: Of the 266 cases, 250 (94%) were successful (group A) and 16 (6%) failed (group B). Average age was significantly higher in group A than in group B (14.9 +/- 12.4 vs. 8.33 +/- 3.93 months) (P < 0.01). Duration of symptoms was significantly shorter in group A than in group B (15.0 +/- 12.5 vs. 25.0 +/- 9.7 h) (P < 0.05). The position of the tip was ascending colon (Ac): A = 34 (14%), B = 1 (6%); right transverse colon (RTc): A = 112 (45%), B = 1 (6%); left transverse colon (LTc): A = 84 (34%), B = 12 (75%); descending colon (Dc): A = 15 (6%), B = 0 (%); and sigmoid colon (Sc): A = 5 (2%), B = 2 (13%). The tip was located in LTc, Dc and Sc significantly more often in group B (14/16, 88%) than group A (104/250, 42%) (P < 0.01). IBR for group B (1.68 +/- 0.47) was significantly larger than group A (1.13 +/- 0.28) (P < 0.01). Differences in parameters of inflammation were not significant. CONCLUSIONS: We found that the position of the tip and IBR are predictive of success of HRI. Having a dedicated team perform HRI using a standardized protocol with consideration of IBR and the position of the tip eliminates bias, fosters reliability and ensures reproducibility, while at the same time it allows patients with inappropriate data to be spared potentially dangerous attempted HRI.

[Long-term outcome of short bowel syndrome].

Short bowel syndrome is a malabsorptive condition, and long-term survival depends upon the process of intestinal adaptation. During this process, patients with short bowel syndrome frequently encounter problems such as developmental disorders, deficiency of vitamins and trace elements, liver dysfunction, catheter sepsis, etc. The treatment of these complications and surgical management, including intestinal lengthening procedures and intestinal transplantation, are described.

Lapprotector use decreases incisional wound infections in cases of perforated appendicitis: a prospective study.

OBJECTIVE: To examine whether Lapprotector, a protective film and ring device for protecting wounds, can prevent wound infection after open appendectomy. METHODS: We performed open appendectomy on 64 patients between 2004 and 2006. In September 2005, we started using Lapprotector to protect the site of incision (McBurney's point). Patients were divided into two groups as follows: Lapp(-), n = 32; Lapp(+), n = 32. Patient demographics were not statistically different and antibiotic protocols were identical. RESULTS: In the Lapp(-) group, the appendix was perforated in seven patients (21.9%) and not perforated in 25 patients (78.1%). In the Lapp(+) group, the appendix was perforated in nine patients (28.1%) and not perforated in 23 patients (71.9%). For perforated cases, incisional wound infection was seen in three out of seven patients (42.9%) in the Lapp(-) group and in no patient (0%) in the Lapp(+) group, a significant difference (p < 0.05, Chi-squared test). For nonperforated cases, wound infection was seen in only one out of 25 patients (4.0%) in the Lapp(-) group. CONCLUSION: We recommend using Lapprotector to prevent incisional wound infection in patients requiring open appendectomy, especially in cases where the appendix is perforated.

Laparoscopy-assisted percutaneous endoscopic gastrostomy.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) placement is associated with considerable complications. We added laparoscopic monitoring to improve outcome. METHODS: Thirty-four patients who had laparoscopy-assisted PEG (LAP-PEG) were reviewed. A 5 mm supraumbilical trocar and two 5 mm working ports were required for LAP-PEG. A needle was placed percutaneously into the stomach under laparoscopic and gastroscopic control. A wire was placed through the needle, encircled with a snare, and the PEG completed. The anterior wall of the stomach was then anchored to the abdominal wall. RESULTS: Thirty-one subjects had cerebral palsy. Age at LAP-PEG ranged from 5 months to 25 years (mean, 8.1 years). Weight ranged from 4.7 kg to 25.9 kg (mean, 12.2 kg). In 23 patients, LAP-PEG was performed with laparoscopic Nissen fundoplication. In 11 patients, it was performed for reasons such as gastric volvulus and nutritional supplementation. Mean operating time was 67 minutes, and all procedures were performed safely without intra- or postoperative complications. CONCLUSION: LAP-PEG is our method of choice for gastrostomy because it allows the first and last parts of a conventional PEG procedure to be well controlled and safe instead of being blind.