Sarcopenia with decreased total psoas muscle area in children with high-risk neuroblastoma.

BACKGROUND: We calculated psoas muscle area (PMA) z-scores in high-risk neuroblastoma patients undergoing treatment to examine the clinical significance of sarcopenia in this cohort. METHODS: We analyzed retrospective data from patients aged 0-18 who were diagnosed with abdominal neuroblastoma between 2005 and 2019 at Samsung Medical Center. Patients categorized as high-risk undergone induction chemotherapy, neuroblastoma excision, and tandem high-dose chemotherapy with autologous stem cell transplantation (HDCT/auto-SCT) were selected. L3-4 lumbar levels on axial CT images were identified and we measured the areas of the left and right psoas muscles to determine tPMA. Total PMA z-scores were calculated using an open online tool. RESULTS: There were 45 boys and 25 girls with a mean age of 3.86 years. CT images taken at initial diagnosis and after tandem HDCT/auto-SCT were selected to calculate tPMA z-scores. Mean elapsed time between the two measurements was 12.91 ± 1.73 months. Mean tPMA z-score significantly decreased from -0.21 ± 1.29 to -0.66 ± 0.97 (p = 0.022). Length of hospital stay was significantly longer in the group of patients whose tPMA z-scores decreased by more than .45 (177.62 ± 28.82 days vs. 165.75 ± 21.34 days, p = 0.049). Presence of sarcopenia at initial diagnosis was a significant risk factor for bacterial infection during neuroblastoma treatment. CONCLUSION: tPMA z-scores in high-risk neuroblastoma patients decreased significantly following a treatment regimen that included induction chemotherapy, tumor resection surgery, and HDCT/auto-SCT. A greater decrease in tPMA z-score was associated with longer hospital stay during treatment.

Clinical Outcome of Ultrasound-Detected Perforated Necrotizing Enterocolitis without Radiographic Pneumoperitoneum in Very Preterm Infants.

OBJECTIVES: To investigate the clinical outcomes of ultrasound (US)-detected perforated necrotizing enterocolitis (NEC) without radiographic pneumoperitoneum in very preterm infants. METHODS: In this single-center retrospective study, very preterm infants who underwent a laparotomy for perforated NEC during their neonatal intensive care unit stay were classified into two groups according to the absence or presence of pneumoperitoneum on radiographs (the case versus the control groups). The primary outcome was death before discharge, and the secondary outcomes included major morbidities and body weight at 36 weeks postmenstrual age (PMA). RESULTS: Of the 57 infants with perforated NEC, 12 (21%) had no pneumoperitoneum on the radiographs and were diagnosed with perforated NEC on the US. In the multivariable analyses, the primary outcome of death before discharge was significantly lower in infants with perforated NEC without radiographic pneumoperitoneum than in those with perforated NEC and radiographic pneumoperitoneum (8% [1/12] vs. 44% [20/45]; adjusted odds ratio [OR], 0.02; 95% confidence interval [CI], 0.00-0.61; p = 0.025). The secondary outcomes (short bowel syndrome, total parenteral nutrition dependence for 3 months or more, the length of their hospital stay, a bowel stricture requiring surgery, sepsis after the laparotomy, acute kidney injury after the laparotomy, and body weight at 36 weeks PMA) did not differ significantly between the two groups. CONCLUSIONS: Very preterm infants with US-detected perforated NEC without radiographic pneumoperitoneum had a lower risk of death before discharge than those with perforated NEC and radiographic pneumoperitoneum. Bowel USs may have a potential role in surgical decision-making in infants with advanced NEC.

Clinical Accuracy of Non-Contact Forehead Infrared Thermometer Measurement in Children: An Observational Study.

We evaluated the clinical reliability and utility of temperature measurements using no-contact forehead infrared thermometers (NCFITs) by comparing their temperature measurements with those obtained using infrared tympanic thermometers (IRTTs) in children. In this observational, prospective, and cross-sectional study, we enrolled 255 children (aged 1 month to 18 years) from the pediatric surgery ward at a tertiary medical center in Korea. The mean age of the children was 9.05 ± 5.39 years, and 54.9% were boys. The incidence rate of fever, defined as an IRTT reading of ≥38.0 °C, was 15.7%. The ICC coefficient for the assessment of agreement between temperatures recorded by the NCFIT and IRTT was 0.87, and the κ-coefficient was 0.83. The bias and 95% limits of agreement were 0.15 °C (−0.43 to 0.73). For an accurate diagnosis of fever (≥38 °C), the false-negative rate was much lower, but the false-positive rate was higher, especially in 6-year-old children. Therefore, NCFITs can be used to screen children for fever. However, a secondary check is required using another thermometer when the child's temperature is >38 °C. NCFITs are proposed for screening but not for measuring the temperature. For the latter, an accurate and reliable thermometer shall be used.

Fluoroscopic criteria for on-site evaluation of failed intussusception reduction during air enema technique.

Background: There is no reliable fluoroscopic criteria for failed intussusception reduction during air enema technique. Methods: This retrospective case-control study included 373 episodes of ileocolic intussusceptions who had undergone air enema under fluoroscopy. All procedures were initially classified by conventional fluoroscopic criteria: presumptive successful procedures (PSP) vs. presumptive failed procedures (PFP). PFP were divided into true failure, false failure, and undetermined groups. The configuration and size of the residual mass were evaluated on fluoroscopic images. Statistical analyses included Mann-Whitney U-test, Fisher's exact test, receiver operating characteristic (ROC) analysis, logistic regression analyses, and Kruskal-Wallis rank sum test with a post hoc Tukey test. Results: PSP was 264 episodes (71%) and PFP was 109 episodes (29%). The true failure was 40 (37%) and false failure was 48 (44%). The true failure group commonly showed a larger size and round configuration for the residual mass than false failure (P<0.001). Multivariable analysis revealed configuration (P=0.004) and transverse diameter (P=0.007) as significant parameters that differentiated true and false failure. The optimal cut-off value of the transverse diameter of the residual mass was 2.3 cm. The sensitivity and specificity of conventional fluoroscopic criteria for failed reduction was 100% and 85%, respectively. The combination of new fluoroscopic findings and conventional criteria increased the specificity to 100%. Conclusions: Fluoroscopic finding of round-shape and larger size residual mass combined with conventional criteria may be useful for differentiating false failure from truly failed enema reduction in children with intussusception.

Economic burden of hospital malnutrition: A cost-of-illness model.

BACKGROUND & AIMS: Hospital malnutrition is a highly prevalent condition that leads to an increased risk of clinical complications and a corresponding increase in healthcare resource utilisation. Despite the high prevalence and adverse clinical consequences, limited data are available on the magnitude of the economic burden associated with hospital malnutrition in Asian countries. The aim of the present analysis was to calculate country-specific estimates of the economic burden of hospital malnutrition in Asia. METHODS: Country-specific cost and prevalence data were used to calculate the incremental healthcare costs attributable to hospital malnutrition in 11 countries in Asia. The cost-of-illness was evaluated from the public perspective. Sources of increased cost included increased length of stay (LOS) and increased antibiotic use in malnourished patients who develop a healthcare-associated infection. Costs were calculated separately for the ward and intensive care unit (ICU) and currencies were converted to US$ to facilitate comparison. RESULTS: The estimated annual economic burden attributable to hospital malnutrition in Asia is $30.1 billion. Increased LOS accounts for the largest portion of the incremental cost, totalling $23.2 billion (77.2%) in the ward and $3.5 billion (11.5%) in the ICU. Medication costs related to the treatment of infectious complications account for an additional $3.4 billion (11.3%). Countries with the highest incremental costs include Japan ($19 billion), South Korea ($2.5 billion), and Taiwan ($2.2 billion). CONCLUSIONS: Hospital malnutrition imposes a substantial economic burden on Asian countries, resulting in an estimated $30 billion per year in additional healthcare costs. This finding underscores the need for rigorous screening and assessment as well as continuous monitoring of nutrition status in hospitalised patients to facilitate early identification and proactive management of hospital malnutrition.

Comparison of Clinical and Radiologic Findings Between Perforated and Non-Perforated Choledochal Cysts in Children.

OBJECTIVE: To compare the clinical and radiologic findings between perforated and non-perforated choledochal cysts in children. MATERIALS AND METHODS: Fourteen patients (mean age ± standard deviation, 1.7 ± 1.2 years) with perforated choledochal cysts (perforated group) and 204 patients (3.6 ± 3.8 years) with non-perforated choledochal cysts (non-perforated group) were included between 2000 and 2019. All patients underwent choledochal cyst excision after ultrasound, CT, or MR cholangiopancreatography. Relevant data including demographics, clinical symptoms, laboratory findings, imaging findings, and outcomes were analyzed. Statistical differences were compared using the Mann-Whitney U test and Fisher's exact test. RESULTS: Choledochal cyst perforation occurred only in children under the age of 4 years. Acute symptoms, including fever (p < 0.001), were more common in the perforated group than in the non-perforated group. High levels of white blood cells (p = 0.004), C-reactive protein (p < 0.001), and serum amylase (p = 0.002), and low levels of albumin (p < 0.001) were significantly associated with the perforated group. All 14 patients with perforated choledochal cysts had ascites, whereas only 16% (33/204) of patients in the non-perforated group had ascites (p < 0.001). In the subgroup of patients who had ascites, a large amount of ascites (p = 0.001), increase in the amount of ascites in a short time (p < 0.001), complex ascites (p < 0.001), and perihepatic pseudocysts (p < 0.001) were more common in the perforated group than in the non-perforated group. CONCLUSION: Children with perforated choledochal cysts have characteristic clinical and radiologic findings compared to those with non-perforated choledochal cysts. In young children with choledochal cysts, perforation should be differentiated in cases with acute symptoms, laboratory abnormalities, and characteristic ascites findings.

Prediction of Recurrence of Completely Resected Pancreatic Solid Pseudopapillary Neoplasms in Pediatric Patients: A Single Center Analysis.

BACKGROUND: Many previous studies have investigated the risk factors for the recurrence of pancreatic solid pseudopapillary neoplasms (SPNs), although a consensus has not yet been reached, despite this effort. We aimed to identify the predictive factors for recurrence in patients with SPNs who underwent complete surgical resection of the tumor. METHODS: We retrospectively analyzed the records of pediatric patients with SPNs who underwent surgical resection at a single center between 2001 and 2018. RESULTS: During the study period, 47 patients with SPNs underwent radical resection of the tumor. The median age of the patients was 14 (8-18) years. R0 resection was confirmed in every case and none of the patients presented with systemic metastasis at the time of diagnosis. The median follow-up period was 53.1 (30.8-150.8) months. Of the 47 patients, only two (4.2%) experienced recurrence. Using comparative analysis, we found that some factors such as a large tumor size, peripancreatic tissue invasion, and capsule invasion did not increase the risk of recurrence of SPNs. Lymph node metastasis was the only significant factor for recurrence in our study (p = 0.043). CONCLUSION: During our single center analysis, we found that only lymph node metastasis was a predictive factor for recurrence of SPNs among patients who underwent complete tumor resection. Long-term follow-up is required to determine whether SPNs will recur if lymph node metastasis is observed after surgery. Furthermore, therapeutic benefits of routine lymphadenectomy or sentinel lymph node biopsy should be investigated in future studies to reduce the risk of recurrence in patients with SPNs.

Abnormal Orientation of the Superior Mesenteric Vessels Detected in Asymptomatic Infants: What Is Its Destiny?

Background: Ultrasonography (USG) has been described as an alternative diagnostic tool for malrotation that evaluates the orientation of the superior mesenteric vessels. However, literature concerning the management of patients who do not have abdominal symptoms is limited. We aimed to review the clinical course of infants showing abnormal orientation of the superior mesenteric vessels on USG who were asymptomatic at the time of diagnosis. Methods: Seventy asymptomatic infants with abnormal orientation of the superior mesenteric vessels in a single center between 2014 and 2018 were retrospectively analyzed. Results: The 70 patients, 21 underwent upper gastrointestinal series (UGIS) and 11 underwent abdominal surgery for other surgical conditions. Among the 32 (45.7%) patients who underwent UGIS or abdominal surgery, 11 were proven to have malrotation. Of the 38 (54.3%) patients who did not undergo UGIS or abdominal surgery, six patients were too unstable to undergo UGIS, five died due to cardiac complications, and the remaining patient developed midgut volvulus and died 3 days after emergency surgery. The remaining 32 patients who did not undergo UGIS or abdominal surgery were discharged without additional tests, and all were asymptomatic until their last follow-up. In the multivariate analysis, history of heart surgery and the presence of more than three anomalies were significantly associated with malrotation. Conclusion: A significant number of malrotation were diagnosed in asymptomatic infants with abnormal orientation of the superior mesenteric vessels on USG. Infants with major cardiac or multiple anomalies need special attention and should undergo UGIS in a promptly manner to confirm malrotation.

Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

BACKGROUND: In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea. METHODS: We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future. RESULTS: The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future. CONCLUSION: The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

Factors Associated with Failure of Pneumatic Reduction in Children with Ileocolic Intussusception.

Intussusception is one of the most common causes of intestinal obstruction in children. Pneumatic reduction is the treatment of choice and has a high success rate. The most common cause of pneumatic reduction failure is the presence of a pathological leading point. We aimed to identify other factors that can lead to pneumatic reduction failure in children with ileocolic intussusception. This was a retrospective study conducted in two centers. Data were collected from January 2013 to December 2014. A total of 156 patients were diagnosed with intussusception and underwent pneumatic reduction, with the exception of one patient with peritonitis. We included patients with ileocolic-type intussusception without apparent pathological leading points. Logistic regression analysis of clinical parameters was performed to identify factors associated with pneumatic reduction failure. Of 156 patients diagnosed with intussusception in both hospitals, 145 were enrolled in the study. The overall efficacy of pneumatic reduction was 85.7%, and surgical reduction was performed in 21 patients. Univariate analysis showed that a high segmented neutrophil count, low hemoglobin level, high body temperature, and higher weight percentile were associated with pneumatic reduction failure. Multivariate analysis showed that a high segmented neutrophil count, low hemoglobin level, and higher weight percentile were significantly associated with pneumatic reduction failure. Pneumatic reduction is safe and effective as a first-line treatment for pediatric intussusception. However, a high segmented neutrophil count, low hemoglobin level, and higher weight percentile are associated with the failure of this treatment.

A multinational observational study of clinical nutrition practice in patients undergoing major gastrointestinal surgery: The Nutrition Insights Day.

BACKGROUND AND AIMS: Patients undergoing major gastrointestinal (GI) surgery, particularly those with malignancies, have a high risk for malnutrition, requiring perioperative nutritional support to reduce complications. During the Nutrition Insights Day (NID), nutritional data of this patient population were documented in seven Asian countries. METHODS: Observational, cross-sectional study with retrospective data collection of nutritional status, calorie/protein targets/intake, and type of clinical nutrition for up to 5 days before NID. INCLUSION CRITERIA: Adult patients following major GI surgery, pre-existing/at (high) risk for malnutrition, on enteral (EN) and/or parenteral nutrition (PN) and latest surgery within 10 days before the NID. EXCLUSION CRITERIA: Burns, mechanical ventilation on NID, oral nutrition and/or oral nutritional supplements (ONS) on the day before the NID, and emergency procedures. RESULTS: 536 patients from 83 hospitals, mean age 58.8 ± 15.1 years, 59.1% males, were eligible. Leading diagnosis were GI diseases (48.7%) and GI cancer (45.9%). Malnutrition risk was moderate to high in 54% of patients, low in 46%. Hospital length of stay (LOS) before the NID was 9.3 ± 19.0 days, and time since last surgery 3.7 ± 2.4 days. Lowest caloric/protein deficits were observed in patients receiving EN + PN, followed by PN alone and EN alone. Type of clinical nutrition, Body Mass Index and LOS on surgical intensive care unit (SICU) and/or surgical ward were independent predictors of caloric and of protein deficit. CONCLUSION: There is a high prevalence of postoperative nutritional deficits in Asian GI surgery patients, who are either preoperatively malnourished or at risk of malnutrition, indicating a need to improve nutritional support and education.

Prenatal ultrasonographic findings of esophageal atresia: potential diagnostic role of the stomach shape.

OBJECTIVE: We investigated prenatal sonographic characteristics of esophageal atresia (EA) with advancing gestation. We focused on the degree of polyhydramnios and the stomach shape. METHODS: This study included 27 EA cases (EA group) and 81 idiopathic polyhydramnios cases (non-EA group). The non-EA group consisted of cases without any fetal structural anomaly, musculoskeletal disorder, chromosomal abnormality, or maternal diabetes. Both groups included only singleton pregnancies. Amniotic fluid index (AFI) and width/length (W/L) ratio as well as the product of width and length (W×L) of stomach were serially assessed during gestation and compared between the 2 groups. To predict EA using W/L ratio and W×L, receiver operating characteristic curve analysis was performed. RESULTS: Polyhydramnios was evident in 77.8% of EA cases. We observed 25.9% and 22.2% EA cases with an absent stomach and a small visible stomach, respectively. After 28 weeks, the EA group manifested significantly higher AFI than the non-EA group. After 32 weeks, W/L ratio in the EA group tended to be lower than that in the non-EA group (32-36 weeks: 1.36 vs. 1.72, P=0.092; >36 weeks: 1.43 vs. 1.63, P=0.024). To predict EA, the calculated area under the curve for W/L ratio was 0.651 after 32 weeks. The diagnosis of EA using a cut-off value of W/L ratio <1.376 showed sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio to be 84.6%, 52.9%, 1.796, and 0.081, respectively. CONCLUSION: A low W/L ratio of stomach after 32 weeks with progressive idiopathic polyhydramnios may be used to predict EA.

Thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: is it a safe procedure in infants weighing less than 2000 g?

BACKGROUND: Since Rothenberg first performed thoracoscopic repair for esophageal atresia with distal tracheoesophageal fistula (EA/TEF) successfully in 2000, thoracoscopic repair has achieved status as a routine procedure worldwide. Previously, an international multicenter study reported that this procedure was not inferior to conventional open surgery. However, thoracoscopic surgery is a highly difficult operation for surgeons and anesthesiologists; as a result, the safety and efficacy of the surgery is still under debate. Considering these circumstances, the purpose of this study was to analyze the results of single-center thoracoscopic surgery and to compare the outcomes relative to the patient's weight at the time of surgery. METHODS: We retrospectively analyzed patients with EA/TEF who underwent thoracoscopic surgery in a single center between October 2008 and February 2017. RESULTS: In total, 41 cases of thoracoscopic repair of EA/TEF were performed. Upon subgrouping by over and under 2000 g of body weight at the time of operation, 34 were found to be over 2000 g and seven were under 2000 g. Intraoperative factors and events were not significantly different between the two groups. Additionally, most of the postoperative outcomes, including the rate of postoperative leakage and strictures, showed no difference. On the other hand, the under 2000 g group had more gastroesophageal reflux requiring fundoplication than did the heavier group (P = 0.04). CONCLUSIONS: The results of this center's thoracoscopic repair of EA/TEF were not inferior to other centers' outcomes. Additionally, the intraoperative and postoperative outcomes were similar despite differences in weight at operation. Therefore, thoracoscopic repair might be a feasible surgical option for infants weighing less than 2000 g when performed by a surgeon and anesthesiologist team who are experienced in pediatric thoracoscopic surgery.

Reversal of Intestinal Failure-Associated Liver Disease by Increasing Fish Oil in a Multi-Oil Intravenous Lipid Emulsion in Adult Short Bowel-Syndrome Patients.

BACKGROUND: Intestinal failure-associated liver disease (IFALD) is a serious complication of parenteral nutrition (PN). We report 2 cases of IFALD, which occurred in adult patients while on a regimen of multi-oil intravenous lipid emulsion containing fish oil. METHODS: Patients initially received PN containing 1-g/kg/d SMOFlipid 20% (SMOFlipid). When IFALD developed, lipid composition in PN was altered to include higher proportions of fish oil. RESULTS: Case 1 was a 23-year-old man with short-bowel syndrome. He had been fully dependent on PN for approximately 11 months with a direct bilirubin level of 15.1 mg/dL. Doses of 0.15-g/kg/d pure fish oil and 0.3-0.6-g/kg/d SMOFlipid were administered for 56 days, and IFALD was resolved 59 days after adding fish oil. Case 2 was an 85-year-old man who received extensive small-bowel resection because of internal herniation and small-bowel necrosis. He had elevated direct bilirubin levels and was diagnosed with IFALD. Fish-oil treatment was initiated after 50 days of receiving PN. The average daily amount of fish oil given was 0.14 g/kg/d. IFALD was resolved 44 days after adding Omegaven (Fresenius Kabi Austria Gmbh, Austria). CONCLUSION: Two patients with advanced IFALD showed reversal of cholestasis by altering the lipid content of their PN to include more fish oil.

Multidisciplinary intestinal rehabilitation in acute type II intestinal failure: Results from an intestinal rehabilitation team.

BACKGROUND: Type II (acute) intestinal failure (IF) is usually caused by complications of abdominal surgery resulting in enteric fistulas or proximal stomas and requires parenteral nutrition (PN) for several months. This study aimed to evaluate clinical management and outcome of type II IF patients in a single center. METHODS: Medical records of patients referred to the Intestinal Rehabilitation Team (IRT) at Samsung Medical Center (Seoul, Korea) were retrospectively analyzed. RESULTS: From 2014 to 2019, 34 patients with IF were referred. 28 patients were type II IF and were included in the analysis. There were 17 males and 11 females. Mean age of patients was 56.7 years. Pathophysiology of IF were high-output stoma in 16 cases, extensive bowel resection (with bowel in continuity) in 7 cases, and enterocutaneous fistula in 5 cases. The catastrophic events necessitating abdominal surgery in the patients were adhesive ileus in 9 cases, superior mesenteric artery thrombosis in 8 cases, internal herniation of bowel in 5 cases, traumatic bowel injury in 3 cases, and ischemic enteritis in 3 cases. Following medical and surgical rehabilitation, 10 patients (35.7%) were weaned off PN and overall mortality was 28.5%. Deaths were related to progression of underlying malignancies in 4 cases, liver failure in 3 cases, and sepsis in 1 case. Thirteen patients underwent surgery to restore bowel continuity. Six postoperative complications occurred in 4 patients (30.7%) and there were no postoperative mortalities. CONCLUSION: Standardized care including restorative surgery resulted in successful outcomes in type II IF patients in this cohort.

Vesicoureteral reflux increases the risk of urinary tract infection prior to corrective surgery in newborn males with anorectal malformation.

PURPOSE: The ideal colostomy type indicated for patients with anorectal malformation (ARM) is disputed. The aim of this study was to analyze the clinical factors associated with urinary tract infection (UTI) prior to corrective surgery in male ARM without perineal fistula having undergone diverting enterostomy. METHODS: A retrospective review of patients diagnosed with ARM and surgically managed at our center from January 2011 to December 2019 was performed. Logistic regression was used to analyze the association between clinical factors and UTI. RESULTS: Eighty boys with ARM without perineal fistula underwent diverting enterostomy and subsequent corrective surgery via laparoscopic-assisted anorectal pull-through. A sigmoid loop colostomy was most often performed (70 patients, 87.5%). Twenty-nine patients (36.3%) were diagnosed with vesicoureteral reflux (VUR), including 14 (48.3%) with febrile UTIs. Six patients had other concomitant genitourinary anomalies excluding VUR. Multivariate logistic regression analysis revealed the presence of VUR as the only independent factor associated with the occurrence of febrile UTI (OR 17.3, 95% CI 3.51-85.26, p < 0.001). CONCLUSION: The development of UTI in newborn males with ARM is associated with the presence of VUR, regardless of stoma type. Voiding cystourethrography should be considered in patients with ARM for early diagnosis of VUR and subsequent antibiotic prophylaxis.

Fish Oil Monotherapy for Intestinal Failure-Associated Liver Disease on SMOFlipid in the Neonatal Intensive Care Unit.

Intestinal failure-associated liver disease (IFALD) is a life-threatening complication of parenteral nutrition (PN) and is most prevalent in the preterm neonatal population receiving long-term PN. In this study, we report the outcome of our experience with fish oil monotherapy for IFALD in a fish oil-based combination lipid emulsion administered to preterm low birth weight infants. Fasting neonates were administered as PN according to our center's nutrition protocol. A diagnosis of IFALD was made when the serum direct bilirubin levels were >2.0 mg/dL in two consecutive measurements that were more than one week apart, without evidence of intrinsic causes of liver dysfunction. The management of IFALD was conducted by switching the lipid emulsion from combination lipid emulsion to fish oil monotherapy at 1.0 g/kg/day, infused over 24 h. Fifteen infants met the criteria for IFALD and received fish oil monotherapy. The median gestational age was 27.5 weeks and the median birth weight was 862.5 g. IFALD was successfully reversed in 11 infants (11/15, 73.3%). The median duration of fish oil monotherapy was 39 days. Direct bilirubin values were initially elevated and then steadily declined from the third week of treatment onward. The enteral tolerance increased in varying degrees during the treatment period. The mean weight gain was 26.0 g/day during fish oil monotherapy. Omegaven® (Fresenius Kabi Austria Gmbh, Graz, Austria) at a dose of 1.0 g/kg/day was well tolerated, and no adverse events related to Omegaven use were seen. The reversal of IFALD in preterm infants on combination lipid emulsion containing fish oil was achieved by switching to fish oil monotherapy.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review.

BACKGROUND & AIMS: Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted. METHODS: We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion. RESULTS: The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs. CONCLUSIONS: Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

The learning curve for thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: A cumulative sum analysis.

BACKGROUND: Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains technically challenging due to the rarity of these procedures. The aim of this study is to report our experience with thoracoscopic repair of type C EA/TEF and to evaluate the learning curve based upon the surgeon's skill level. METHODS: We retrospectively reviewed data of thoracoscopic EA/TEF repair performed in our center between October 2008 and May 2019. The learning curve was evaluated using the cumulative sum (CUSUM) method based on operative time. RESULTS: Of the 50 consecutive cases evaluated, the mean birth weight was 2634 ±â€¯608 g and the median age at operation was 3 days (range, 1-29 days). The mean operation time was 144 ±â€¯65 min. Anastomosis leakage occurred in 3 cases (6%) and strictures requiring balloon dilatations occurred in 16 cases (32%). The CUSUM analysis evaluated a learning curve of approximately 10 cases of thoracoscopic type C EA/TEF repair. A lower gestational age was associated with longer operation time. CONCLUSIONS: Thoracoscopic repair of type C EA/TEF is a feasible and safe procedure. The number of procedures required to achieve a stable learning curve was 10. The learning phase may be shortened by adequate set-up under the supervision of an expert endoscopic surgeon. TYPE OF STUDY: Retrospective Comparative Treatment Study. LEVEL OF EVIDENCE: III.