Prehabilitation: The Impact of Preoperative Exclusive Enteral Nutrition on Paediatric Patients With Crohn Disease.

Exclusive enteral nutrition (EEN) is effective in inducing remission in paediatric Crohn Disease (CD) and has been shown to reduce inflammation and improve outcomes in adult CD patients when used before resectional surgery. This retrospective study demonstrates that preoperative EEN is achievable in paediatric CD patients undergoing right hemicolectomy and is associated with positive peri-operative outcomes. Seventeen patients (8 who received preoperative EEN and 9 who did not) were included in the study. Six of 8 (75.0%) managed EEN orally; 1 via nasogastric tube and another via a previously sited gastrostomy. Use of preoperative EEN was associated with a decreased rate of moderate/severe disease on resection pathology (5/8 [62.5%] vs 9/9 [100%]; P = 0.04). Larger studies are required to determine the wider potential benefits of preoperative EEN on postoperative outcomes within paediatric practice.

The challenges of widening access to the medical profession: how to facilitate medical careers for those at a genuine disadvantage.

This article was migrated. The article was marked as recommended. Widening Participation (WP) for medical school entry has been politically encouraged to ensure access and participation for underrepresented groups that are rarely able to gain access to this high demand profession. Those who reside in the 20% most deprived postcodes in Scotland (SIMD20, Scottish Index of Multiple Deprivation) are much less likely to apply for medical school entry and even less likely to succeed. The National outreach programme of Scotland (Reach) aims to rectify the existing situation by encouraging and supporting students from working class backgrounds to apply to high demand courses, including medicine, and has achieved great success in helping pupils from low progression secondary schools to gain a place in Glasgow Medical School. However, some of the Reach students have similar demographics as the rest of the medical school class and arguably do not genuinely belong in the target group. To address this, a second flag, based on SIMD20/40 residence, was employed. Applying more than one WP flag however - while substantially improving the accurate targeting of this programme and helping those who truly are multiply deprived - reduces the Reach-eligible applicant pool to the point of undermining the high WP targets imposed on Universities. But using only a single criterion of SIMD20/40 residence or school progression rate would inappropriately benefit some pupils that are actually not genuinely disadvantaged. Ideally, individualised indicators such as eligibility for Free School Meals, receipt of an Educational Maintenance Allowance and/or a UKCAT bursary, would complement residential data and school progression rates. This paper reflects on the evolution of the admissions practices at Glasgow Medical School that are designed to meet the targets and create a medical workforce reflecting the population it serves.

Treatment of tracheomalacia with aortopexy in children in Glasgow.

OBJECTIVE: The aim of this study was to assess outcomes of infants and children undergoing aortopexy and to try and establish which children would derive the greatest benefit from this complex intervention. Materials and METHODS: This is a retrospective case series in a pediatric tertiary referral hospital between 1993 and 2012. A case sheet review was performed to collect demographic data and identify outcomes for each child. The effects of the subtype of tracheomalacia, weight at surgery, symptoms at presentation, surgical approach, and preoperative ventilation were considered. RESULTS: There were 30 children who underwent aortopexy during the study period. Of the 30 children in the study, 21 children (70%) were male. The gestational age at birth ranged between 25 and 41 weeks (9 children [30%] were preterm). Age at surgery was between 2 and 140 weeks (mean; 31.5 weeks, median; 26 weeks). The onset of symptoms was between birth and 18 months (mean; 3.8 months, median; 3.5 months). The presenting symptoms were stridor (n = 9; 30%), failed extubation (n = 4; 13%), death attacks (n = 8; 27%), and cyanosis (n = 9; 30%). The underlying pathology was primary in 10 children (33%) and secondary in 18 children. The diagnosis was made by bronchoscopy in 26 children (93%). Imaging was performed in 25 children (83%). Aortopexy in our institution is performed by general pediatric surgeons (n = 8; 27%) and cardiothoracic surgeons (n = 22; 73%). In the immediately postoperative period, 25 children (83%) were thriving. Of the children that required another procedure; 1 child was reintubated (3%), 2 children had a tracheostomy (6%), 1 child had a stent (3%), and 2 children died (6%). Clinical follow-up of these children was between 1 month and 12 years. Long term, in 22 children (73%) were asymptomatic. CONCLUSION: There were no clinical predictors of outcome identified, but aortopexy is a safe effective procedure for children with severe tracheomalacia.

A multidisciplinary team model of caring for patients with perianal Crohn's disease incorporating a literature review, topical therapy and personal practice.

BACKGROUND: Crohn's disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist. METHODS: This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images. RESULTS: Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management-in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles. CONCLUSIONS: Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.

Choledochal malformations: the Scottish experience.

INTRODUCTION: Excisional surgery for choledochal malformations in Scotland is currently performed in three specialist pediatric surgical centers using open or laparoscopic-assisted techniques. We reviewed the outcome of children who had excisional surgery in Scotland between 1992 and 2010. MATERIALS AND METHODS: Case notes for all patients undergoing excisional surgery in any of the three specialist pediatric surgical centers in Scotland between 1992 and 2010 were retrospectively reviewed. RESULTS: A total of 25 patients were identified, with a female preponderance of 4:1. Of these, three patients (12%) were diagnosed by antenatal ultrasound scan. The commonest presenting symptoms were anorexia (56%), abdominal pain (52%), and jaundice (52%). Only 20% had the classical triad of abdominal pain, jaundice, and a palpable mass. Using the King's College Hospital classification, 14 patients had type 1 malformations, 8 had type 4 malformations, and 3 had type 2 malformations. Median age at operation was 2 years (range 35 days to 13.5 years). Two centers performed open excision while the third center used primarily a laparoscopic-assisted technique. Median follow-up was 2.1 years (range 30 days to 11.9 years). Three patients (12%) required repeat laparotomy. The wound infection rate was 8% (n=2). The recurrent cholangitis rate was 8% (n=2). There was one late death due to adhesive small bowel obstruction, 4 years after surgery. To date, no patient has developed biliary tree stones or liver failure. CONCLUSIONS: Choledochal malformation excisional surgery, either open or laparoscopic assisted, can be safely performed in appropriately equipped, pediatric surgical centers in Scotland by experienced pediatric surgeons.

Campylobacter jejuni 81-176 forms distinct microcolonies on in vitro-infected human small intestinal tissue prior to biofilm formation.

Human small and large intestinal tissue was used to study the interaction of Campylobacter jejuni with its target tissue. The strain used for the study was 81-176 (+pVir). Tissue was processed for scanning and transmission electron microscopy, and by immunohistochemistry for light microscopy. Organisms adhered to the apical surface of ileal tissues at all time points in large numbers, in areas where mucus was present and in distinct groups. Microcolony formation was evident at 1-2 h, with bacteria adhering to mucus on the tissue surface and to each other by flagellar interaction. At later time points (3-4 h), biofilm formation on ileal tissue was evident. Flagellar mutants did not form microcolonies or biofilms in tissue. Few organisms were observed in colonic tissue, with organisms present but not as abundant as in the ileal tissue. This study shows that C. jejuni 81-176 can form microcolonies and biofilms on human intestinal tissue and that this may be an essential step in its ability to cause diarrhoea in man.

A roadmap for the establishment of pediatric laparoscopic fundoplication.

AIM: The way to introduce laparoscopic fundoplication (LF) to a pediatric surgical unit has not been well described. We have taken a measured approach to introducing LF and report our experience in this paper. METHODS: All patients undergoing LF from the first case in April 2003 to December 2007 were reviewed retrospectively. Cases were identified from theater and discharge databases, and data were captured by using a structured proforma. RESULTS: Eighty-five LFs were performed on 51 males and 34 females, with a median age of 46.5 months (range, 2-218). Fifty-one cases (60%) were neurologically impaired; a further 26 (31%) had significant comorbidity. Seventy-eight (92%) cases were performed by, or under the supervision of, the two senior authors. The first 10 cases were performed under the mentorship of a visiting surgeon from an established pediatric laparoscopic center. Thereafter, LF was conducted as a two- then a one-consultant operation and was finally performed primarily by trainees under consultant supervision. The total number of LFs increased from 4 in 2003 to 29 in 2007. Nine major complications occurred in 8 patients (5 gastric perforations, 1 colonic gastrostomy tube insertion, 1 nasogastric tube sutured into a wrap, 1 midgut, and 1 gastric volvulus). Seven cases required a conversion to an open fundoplication. There was no 30-day mortality. Six patients have died since surgery; in none of the patients was the LF implicated. CONCLUSION: We recommend a measured approach to the introduction of LF with the transition from mentorship to local consultant practice and, finally, to a trainee procedure under consultant supervision. This approach yielded satisfactory results while minimising the disruption to trainee experience.

Campylobacter jejuni-infected human epithelial cell lines vary in their ability to secrete interleukin-8 compared to in vitro-infected primary human intestinal tissue.

Campylobacter jejuni causes symptoms of acute inflammatory diarrhoea in man. C. jejuni interaction with epithelial cells elicits interleukin-8 (IL-8) production, and IL-8 recruits neutrophils to sites of infection. Cell culture models of bacterial interaction with epithelium are useful to define bacteria-host interaction and are used because it is thought they mimic the same bacteria-host cell interaction in the natural disease. This study looks at the ability of C. jejuni strains to elicit IL-8 production from a variety of cell lines previously used for investigating the interaction of C. jejuni with host cells. A spectrum of IL-8 responses was observed, with minimal IL-8 elicited from Caco-2 cells and more marked responses elicited from HeLa and T84 cells. These in vitro-infected cell line responses were compared to IL-8 production from in vitro C. jejuni-infected human colonic and ileal tissue. The in vitro-infected tissue elicited the highest IL-8 responses and the cytokine was manifested earlier compared to the infected cell lines.

Campylobacter jejuni activates mitogen-activated protein kinases in Caco-2 cell monolayers and in vitro infected primary human colonic tissue.

The mitogen-activated protein kinases (MAPKs) play a central role in many host signalling pathways. These signalling proteins are known to be involved in host responses against invasive bacteria including generation of chemotactic and inflammatory cytokines. It was hypothesized that Campylobacter jejuni may activate MAPKs, as intestinal infection may induce a clinical and pathological picture of acute colonic inflammation. Infection of Caco-2 cell monolayers (human colonic epithelial cell line) and human colonic tissue with C. jejuni in vitro demonstrated increased MAPK activity for ERK 1/2 (p44/42 MAPK), JNK and p38 MAPKs. Kinase activity and phosphorylated forms were increased in infected Caco-2 cells and human colonic explants, suggesting that these pathways are important in inflammatory responses induced by C. jejuni in man.

Rescue of the hypoplastic lung by prenatal cyclical strain.

We determined the effects of sustained and cyclical prenatal mechanical strain on the hypoplastic lung of the ovine model of congenital diaphragmatic hernia. Over a period of 4 weeks in late gestation, repeated cyclical tracheal occlusion for 23 hours with 1-hour release stimulated minimal growth, but promoted maturation with the development of a saccular lung. In contrast, a cycle consisting of 47 hours with 1-hour release induced optimal lung growth and morphologic maturation of the hypoplastic lung parenchyma. Sustained occlusion resulted in exaggerated lung growth, exceeding that of unaffected controls, and abnormal alveolar development. The extent of induction of lung growth by mechanical strain was inversely proportional to the number of alveolar type II cells remaining in the lung epithelium. These studies show that, although mechanical strain is capable of inducing lung growth and differentiation, cyclical strain is a prerequisite for normal development and that mechanically induced growth occurs at the expense of the alveolar type II cell. We conclude that cyclical strain may allow optimal alveolar development while maintaining a population of alveolar type II cells and may thus facilitate an improvement in postnatal lung function in infants with congenital diaphragmatic hernia.

Evolution of a percutaneous fetoscopic access system for single-port tracheal occlusion.

BACKGROUND/PURPOSE: Prenatal tracheal occlusion currently is being assessed as a treatment modality for congenital diaphragmatic hernia (CDH). The development of a totally percutaneous fetoscopic access system would help avoid the need for maternal laparotomy and reduce the morbidity rate of fetal surgical procedures for the mother. Laparoscopic radial expansion sheaths and Seldinger technique-based vascular catheters both have been advocated as means of achieving amniotic cavity access. The authors have investigated these 2 systems in an attempt to develop a reliable method for achieving safe percutaneous fetoscopic access and present the first successful attempt to deploy an intratracheal balloon using an entirely percutaneous approach through a single port in an ovine model. METHODS: A number of prototype systems were evaluated sequentially over a 3-year period in an ovine model: (1) the radially expanding InnerDyne step port system, (2) a new rigid cannula with a bulbous/sharp end preloaded onto the radially expanding InnerDyne port, (3) a conical removable addition to the rigid cannula in 2, (4) a modified bulbous/sharp ended cannula incorporating a circumferential protective insert, (5) a rigid split sheath with the radially expanding port placed through the lumen of the split sheath, (6) a flexible introducer and dilator with the split sheath (used in the Seldinger placement of central lines), and (7) a 2-needle approach using a superelastic shape-memory alloy Nickel-Titanium wire with the flexible dilator and sheath, incorporating a side perfusion port. For balloon tracheal occlusion, live anaesthetized time-mated pregnant ewes were used at 110 days' gestation. Tracheobronchoscopy was achieved using a 3-mm 0 degrees telescope, and the cutaneotracheal tract was secured by a 3.3-mm sheath incorporating a side-perfusion port. The rigid telescope was replaced by a flexible choledochoscope preloaded with a silicone balloon. The balloon was deployed 2 cm above the carina proximal to the right upper lobe bronchus. RESULTS: The many problems encountered in the evolution of the preferred system related mainly to separation and tenting of the chorioamniotic membranes in the ovine uterus and inconsistent access to the fetal parts of interest. Each resulted in significant modifications to our approach. Furthermore, the use of rigid access devices commonly caused fetal injury. Successful access to the intrauterine cavity and cannulation of the trachea was achieved consistently with minimal trauma, irrespective of fetal position by method 7. Multiple port placement allowed visualization of the entry of all components of the system confirming minimal chorioamniotic membrane separation and tenting. Single port tracheal occlusion was undertaken first on 6 cadavers before being performed successfully on 3 live anaesthetized ewes. Fetoscopic access and cannulation of the trachea was achieved consistently in all live animals irrespective of fetal position. CONCLUSIONS: This modified Seldinger technique using the unique properties of the memory-shaped alloy wire for initial uterine access offers a safe method for the percutaneous placement of fetoscopic ports in the ovine model for prenatal intervention. Successful placement of a tracheal balloon entirely through a single percutaneously placed port represents a further advance in prenatal therapy for CDH.