Upper Ureteral Reconstruction with a Tapered Descending Colon after Failed Pyeloplasties in a 13-Year-Old Boy.

An 11-year-old boy was referred for further management of a 6-cm-long grossly stenosed ureter following two failed left ureteropelvic junction (UPJ) obstruction repairs elsewhere. A tapered segment of the descending colon (TDC) was used successfully for ureteral reconstruction. The UPJ was exposed through a left flank incision. The stenosed segment was excised; both ends appeared severely inflamed and thickened. Tissue interposition was required and ureteroplasty with a TDC was performed by incising the peritoneum adjacent to the excised ureter to mobilize the descending colon to the retroperitoneal space. To prepare the TDC, an 8-cm segment of the colon with intact blood vessels was isolated, tapered, and sutured into a funnel shape using a 14-Fr catheter as a temporary stent. After colocolostomy, the colon was returned to the abdominal cavity, the peritoneum was closed carefully to prevent vascular compromise, and the TDC was anastomosed to the ureter and renal calyx with interrupted absorbable sutures. A double J stent (DJS) and percutaneous nephrostomy tube were placed. Postoperative recovery was uneventful. The DJS was removed on day 50 after confirming smooth urine flow through both the ureter-TDC and calyx-TDC anastomoses. Diuretic renography performed 68 days postoperatively was unobstructed. The patient is currently well after 12 months follow-up. This would appear to be the first report of a TDC being used to create a funnel-shaped segment to reconstruct a long, grossly stenosed ureter. The TDC is simpler than the re-tubularizing colon but requires monitoring for postoperative mucus-related complications and malignant transformation.

Successful all robotic-assisted excision of highly malignant mediastinal neuroblastoma in a toddler: A case report.

An otherwise well 28-month-old girl presented with fever/left thigh pain. Computed tomography identified a 7 cm right posterior mediastinal tumor extending to the paravertebral and intercostal spaces with multiple bone and bone marrow metastases on bone scintigraphy. Thoracoscopic biopsy diagnosed MYCN non-amplified neuroblastoma. Chemotherapy shrank the tumor to 5 cm by 35 months of age. Robotic-assisted resection was chosen because the patient was large enough and public health insurance coverage was available. At surgery, the tumor was well-demarcated by chemotherapy and dissection posteriorly from the ribs/intercostal spaces and medially from the paravertebral space and azygos vein was facilitated by superior visualization/instrument articulation. The capsule of the resected specimen was intact on histopathology, confirming complete tumor resection. Despite minimum distance specifications between arms, trocars, and target sites with robotic assistance, excision was safe without instrument collisions. Robotic assistance should be actively considered for pediatric malignant mediastinal tumor provided the thorax is of adequate size.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children: Value of Robotic Assistance.

AIM: Retroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared. METHODS: All subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and -1 if robo-RP appeared to be inferior. RESULTS: Robo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously. CONCLUSIONS: The RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended. LEVEL OF EVIDENCE: III.

High intestinal vascular permeability in a murine model for Hirschsprung's disease: implications for postoperative Hirschsprung-associated enterocolitis.

PURPOSE: Intestinal vascular permeability (VP) in a murine model for Hirschsprung's disease (HD) and postoperative Hirschsprung-associated enterocolitis (HAEC) were investigated. METHODS: Intestinal VP was determined using a Miles assay using 1% Evans blue injected into a superficial temporal vein of newborn endothelin receptor-B KO HD model (KO) and syngeneic wild-type (WT) mice (n = 5, respectively). Extravasated Evans blue in normoganglionic ileum (Ng-I), normoganglionic proximal colon (Ng-PC) and aganglionic distal colon (Ag-DC) was quantified by absorbance at 620 nm. Quantitative polymerase chain reaction (qPCR) for Vascular Endothelial Growth Factor A (VEGF-A), VEGF-B, CDH5, SELE and CD31, and immunofluorescence for CD31 were performed. RESULTS: VP was significantly higher in Ng-I, Ng-PC, and Ag-DC from KO than WT (p < 0.01, p < 0.05, and p < 0.05, respectively). qPCR demonstrated upregulated VEGF-A in Ng-I and Ag-DC, VEGF-B in Ng-I, and SELE in Ng-I and Ng-PC (p < 0.05, p < 0.05, p < 0.05, p < 0.01 and p < 0.05, respectively), and downregulated CDH5 in Ng-I and Ng-PC from KO (p < 0.05, respectively). Expression of CD31 mRNA in Ng-I and Ag-DC from KO was significantly higher on qPCR (p < 0.05) but differences on immunofluorescence were not significant. CONCLUSIONS: VP may be etiologic for postoperative HAEC throughout the intestinal tract even after excision of aganglionic bowel.

Quality of life after type-A esophageal atresia surgery: changes over time and effect of pre-anastomotic elongation.

AIM: To assess mid-/long-term postoperative quality of life (QOL) of esophageal atresia (EA) patients. METHODS: Modified gastrointestinal quality-of-life index surveys were administered to postoperative EA patients who were at least 7 years old at evaluation to assess three topics about general lifestyle (GL), five topics about EA, and four topics about mental health (MH). For MH, caregivers were also interviewed, but separately. Subjects were divided according to age: children (7-12 years old), teenagers (13-19), and adults (20 and over) and compared according to Foker or Kimura elongation (FK) or bougienage stretching (BS). RESULTS: There were 22 patients evaluated. Responses for GL, EA, and MH did not differ significantly between age groups, but MH responses by caregivers for subjects who were children or teenagers scored significantly lower than responses they made themselves. For primary esophageal elongation technique (PET), age at esophagoesophagostomy was significantly higher in FK. Despite FK scoring 15.1 versus 12.4 for BS during EA evaluation, this difference was not statistically significant. CONCLUSION: Changes in QOL responses according to age were unremarkable. However, discrepancies in MH indicate that subjects felt better than their caregivers thought. PET did not appear to influence QOL.

Changes in postoperative quality of life of pediatric total colonic aganglionosis patients: effect of pull-through technique.

AIM: To assess mid-/long-term quality of life (QOL) of total colonic aganglionosis (TCA) patients. METHODS: Modified pre-existing QOL assessment tools for general lifestyle (GL), bowel function (BF), and mental health (MH) were administered to postoperative TCA patients from five institutions, who were at least 7 years old to compare Duhamel (with pouch) and Swenson/Soave (without pouch) techniques between children (Ch 7-12 years old), teenagers (Tn 13-19), and adults (Ad 20 and over). For MH, caregivers were also interviewed, but separately. Maximum scores were 12 for GL/MH and 18 for BF. RESULTS: There were 32 subjects. GL and BF scores increased significantly from Ch (GL 4.8 ± 2.5, BF: 11.3 ± 4.6) to Tn (GL 7.8 ± 2.6, BF 16.2 ± 3.0); scores for MH did not change significantly. Mean caregiver MH scores were significantly lower than mean subject MH scores for all age groups (subject scores: 10.1, 10.7, 10.7 versus caregiver scores: 6.8, 7.8, 8.1 for Ch, Tn, Ad, respectively). PT technique/presence of a pouch did not influence the incidence of enterocolitis or QOL scores. CONCLUSION: MH responses showed subjects felt better than caregivers believed. This discrepancy could cause conflict despite steadily improving GL/BF. QOL was unaffected by PT technique/presence of a pouch.

Decreased incidence of intussusception during the COVID-19 pandemic. Trends in pediatric surgical emergencies.

PURPOSE: Recent reports suggest that the COVID-19 pandemic may be influencing disease morbidity. The purpose of this study was to investigate pandemic-related changes in the incidence of pediatric surgical emergencies. METHODS: Data from patients with one of 8 typical conditions considered to be pediatric emergencies who presented at 3 hospitals close to central Tokyo were collated retrospectively from accident and emergency (AE) department records for 2020 and compared with data for 3 years prior to 2020. RESULTS: All subjects had similar demographic profiles. The total number of pediatric AE attendances from 2017 to 2020 was 2880 (2017: n = 600, 2018: n = 736, 2019: n = 817, and 2020: n = 727). Annual attendances were similar. Of the 8 conditions, there were significantly less cases of intussusception in 2020 than previously (23/727; 3.1% versus 132/2153; 6.1%) p < 0.01 and the number of emergency surgical interventions for intussusception was also significantly less in 2020 (0/23; 0% versus 13/132; 9.8%) p < 0.01. CONCLUSION: The implementation of preventative measures to combat the COVID-19 pandemic in 2020 would appear to have influenced the etiopathogenesis of intussusception enough to significantly decrease its overall incidence and the requirement for emergency surgical intervention.

Perforation in pediatric non-complicated appendicitis treated by antibiotics: the real incidence.

PURPOSE: The incidence of perforation during antibiotic therapy (AT) of children triaged as non-complicated acute appendicitis (NC-Ap) was investigated. METHODS: Abdominal ultrasonography (US) and/or computed tomography (CT) scans from cases of perforation identified at appendectomy for failed AT were reassessed blindly by a panel of board-certified specialists for any evidence of pre-AT morbidity suggestive of perforation. RESULTS: Of 521 cases triaged as NC-Ap, symptoms resolved with AT in 452 cases (86.8%). All 69/521 (13.2%) cases with persistent symptoms had urgent appendectomy, and 12/521 (2.3%) were found to have perforated. Blind reassessment of US and/or CT scans from these cases identified seven with evidence of perforation when they were triaged as NC-Ap. Thus, the actual incidence of perforation during AT for NC-Ap was actually 12-7 = 5/521 (0.95%). CONCLUSIONS: Perforation is generally believed to be a complication of AT, but inappropriate triaging of cases for AT can bias results by artificially inflating the number of perforations, in this study, by more than double. We are the first to assess the unbiased incidence of perforation during AT for NC-Ap, by reassessing pre-AT US and/or CT scans. The incidence of perforation during AT is actually negligible.

Compromised vitality of spermatozoa after contact with colonic mucosa in mice: implications for fertility in colon vaginoplasty patients.

AIM OF THE STUDY: Colon vaginoplasty (CV) is often performed for cloacal malformation (CM). We used mice to study the vitality of spermatozoa after contact with colonic mucosa as a factor contributing to infertility. METHODS: Spermatozoa isolated from the epididymides of C57BL/6J male mice (n = 23) were syringed directly into the vaginas (Vag-group) or colons (Colo-group) of female mice (n = 45). Vitality was determined by assessing motility using computer-assisted sperm analysis, viability by staining with SYBR-14 and propidium iodide, and fertility by in vitro fertilization, prior to deposition, and at 5, 10, 30, and 60 min after deposition. MAIN RESULTS: Motility was significantly decreased in Colo only at 10 and 60 min. Viability of Colo spermatozoa was significant at all assessment times, except at 10 min. Normal fertilization was observed with all Vag spermatozoa, but with Colo, there was arrest of embryo development with spermatozoa collected at 5 and 10 min, and no fertilization with spermatozoa collected at 30 and 60 min. CONCLUSIONS: The vitality of spermatozoa is compromised by contact with colonic mucosa which could contribute to infertility in CM after CV, because their ovaries and fallopian tubes are considered to be normal.