Association between gastrointestinal perforation and patent ductus arteriosus in extremely-low-birth-weight infants: a retrospective study of our decade-long experience.

PURPOSE: Management of persistently patent ductus arteriosus (PDA) in extremely low-birth-weight infants (ELBWIs) requires attention due to the risk of tissue hypoperfusion. We investigated the association between PDA and gastrointestinal perforation. METHODS: We performed a retrospective chart review from 2012 to 2021. Preterm (≤ 32 weeks) ELBWIs with PDA after birth who developed necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and idiopathic gastric perforation were included; ELBWIs with congenital heart disease were excluded. Data were analyzed using chi-squared tests with Yates; correction, and Student's t test. RESULTS: Five hundred thirty-five preterm ELBWIs were analyzed, including 20 with NEC, 22 with FIP, and 1 with gastric perforation. In NEC and FIP, the ductus arteriosus remained open in 40% (4/10) and 63.6% (14/22) of cases, respectively, and cyclo-oxygenase inhibitor treatment showed poor efficacy (p = 0.492 and 0.240). The incidence of perforation in NEC (4/9 vs. 6/11, p = 0.653), mortality in NEC (3/4 vs. 3/6, p = 0.895) and FIP (6/14 vs. 3/8, p = 0.838) did not differ according to whether the PDA persisted or resolved. CONCLUSION: The presentation of PDA did not affect the mortality or morbidity of ELBWIs. However, it is essential to consider the possibility of gastrointestinal perforation due to decreased organ blood flow caused by ductal steal.

An analysis of the correlation between the efficacy of training using a high-fidelity disease-specific simulator and the clinical outcomes of laparoscopic surgery for congenital biliary dilatation in pediatric patients.

PURPOSE: The present study clarified the efficacy of repeating laparoscopic surgery training using a disease-specific simulator and investigated the clinical outcomes of laparoscopic surgery for congenital biliary dilatation (CBD) in pediatric patients after training. METHODS: A high-fidelity laparoscopic hepaticojejunostomy simulator was used. Four pediatric surgeons performed practice laparoscopic hepaticojejunostomy three times using the simulator. The details of forceps manipulation during the task were analyzed. The clinical outcomes of 13 CBD cases treated with laparoscopic surgery in our institution were also evaluated based on medical records. RESULTS: The time required to complete the task became significantly shorter each successive time (1st: 1062.18 ± 346.79 s vs. 3rd: 717.44 ± 260.80 s, p = 0.039). There were no significant differences in the total path length of the right forceps (1st: 55.56 ± 23.21 m vs. 3rd: 28.25 ± 17.01 m, p = 0.17), total path length of the left forceps (1st: 47.79 ± 20.79 m vs. 3rd: 31.83 ± 17.62 m, p = 0.17), average velocity of the right forceps (1st: 58.78 ± 21.29 mm/s vs.44.98 ± 10.25 mm/s, p = 0.47), or the average velocity of the left forceps (1st: 50.39 ± 19.25 mm/s vs. 52.26 ± 19.59 mm/s, p = 0.78). Regarding the clinical outcome, all CBD patients underwent laparoscopic surgery performed by practiced pediatric surgeons who had no experience. The operative time was 545.53 ± 91.01 min, and the blood loss was 24.2 ± 25.8 ml. There were no cases of open conversion, intraoperative adverse events, or anastomotic leakage. CONCLUSION: Disease-specific simulator training significantly decreased the task performance time by improving the forceps manipulation economy. In addition, simulator training may improve the operative safety and quality of laparoscopic hepaticojejunostomy in pediatric CBD patients.

Retroperitoneal teratomas in children: a single institution experience.

PURPOSE: Retroperitoneal teratomas (RPTs) are rare in infants. We report our experience of treating pediatric patients with RPTs over many years at a single institution, with the aim of developing a safe and secure operative strategy for RPTs in infants. METHODS: We reviewed the medical records of patients who underwent treatment for RPTs in our institution between April, 1984 and December, 2017, to analyze their background and clinical data. The diagnosis of RPT was confirmed histologically in all patients. RESULTS: The subjects of this retrospective analysis were 14 pediatric patients (female, n = 11; male, n = 4), ranging in age from 6 days to 12 years, 11 (73.3%) of whom were under 1 year of age. Complete surgical resection was performed in all patients. The tumor ruptured during surgery in four (26.7%) patients and perioperative vessel injuries occurred in six (40.0%) patients, resulting in nephrectomy in one (6.7%). Three (20.0%) patients suffered unilateral renal dysfunction as a surgical complication. Only one patient received postoperative chemotherapy. All patients were free of disease at the time of writing. CONCLUSION: Perioperative complications are not uncommon during surgery for RPTs, despite their benign nature. Preoperative imaging evaluation is important and operative management may be challenging. Because of the favorable prognosis and the frequency of adverse events in surgery, partial resection or split excision is sometimes unavoidable. Meticulous follow-up for recurrence is required for such patients.

The long-term health-related quality of life in patients operated for choledochal cyst.

PURPOSE: Late postoperative complications in choledochal cyst (CC) patients are severe problems that affect the quality of life (QOL). We evaluated the postoperative complications and health-related QOL (HRQOL) of CC patients ≥ 18 years of age. METHODS: From April 1984 to January 2018, 114 CC patients underwent definitive surgery at our institution. Seventy-nine patients reached ≥ 18 years of age. The HRQOL was assessed using the Japanese version of the SF-36v2. Eight health domain (physical functioning, role-physical, body pain, general health, role-emotional, vitality, mental health, and social functioning) scores and three component summary [physical component summary, mental component summary (MCS), and role-social component summary] scores were compared between the patients with and without complications (C [+] vs. C [-]). RESULTS: Thirty-five patients answered the questionnaires. Twelve patients had postoperative complications. Among the eight domains, the score of general health was significantly lower in C [+] patients than in C [-] patients (p = 0.0488). Among the three component scores, the MCS score in C [+] patients was lower than in C [-] patients without significance (p = 0.0953). CONCLUSIONS: The HRQOL of CC patients ≥ 18 years of age was mostly acceptable. However, postoperative complications can impair the sense of well-being and affect the mental health.

A Randomized Trial to Compare the Conventional Three-Port Laparoscopic Appendectomy Procedure to Single-Incision and One-Puncture Procedure That Was Safe and Feasible, Even for Surgeons in Training.

BACKGROUND: Single-incision laparoscopic surgery has emerged; however, the procedures might be complicated for trainees. We compared the clinical outcomes of conventional three-port laparoscopic appendectomy (CLA) and single-incision and one-puncture laparoscopic appendectomy (SIOPLA) by attending pediatric surgeons (APSs) and surgeons in training (SITs). MATERIALS AND METHODS: We reviewed the clinical outcomes of 72 randomized laparoscopic appendectomies that were consecutively performed by SITs and APSs for a 2-year period. The cases were categorized according to type of surgeon. Finally, 10 CLA and 18 SIOPLA procedures were performed by SITs, and 24 CLA and 20 SIOPLA procedures were performed by APSs. The operative time, blood loss, analgesic use, complications, and hospital stay were analyzed. RESULTS: There were no significant differences in any of the evaluation points between CLA and SIOPLA. CONCLUSIONS: SIOPLA is not inferior operation to CLA, and the postoperative outcomes of SIOPLA were satisfactory. Thus, SIOPLA was safe and feasible for young surgeons to perform.

The effect of intravenous lipid emulsions and mucosal adaptation following massive bowel resection.

AIMS AND OBJECTIVES: Fish oil (FO) lipid emulsion and a new lipid emulsion (SMOF) are important treatments for intestinal failure-associated liver disease. We evaluated the efficacy of FO and SMOF lipid emulsion on intestinal mucosal adaptation using a total parenteral nutrition (TPN)-supported rat model of short bowel syndrome. MATERIAL & METHODS: Sprague-Dawley rats underwent jugular vein catheterization and 90% small bowel resection and were divided into three groups: TPN with soy bean oil lipid emulsion (SO group), FO lipid emulsion (FO group), or SMOF (SMOF group). On day 13, the rats were euthanized, and the small intestine was harvested. The microscopic morphology and crypt cell proliferation rate (CCPR) were then evaluated. RESULTS: The villus height of the ileum in the SMOF group was significantly higher than in the SO group. The crypt depth of the intestine in the SMOF group was significantly lower than in the SO group. The CCPRs of the intestine in the FO and SMOF groups were both higher than in the SO group. CONCLUSIONS: Lipid emulsion affected the bowel morphology, such as the mucosa as well as the intestinal smooth muscle. Further studies are needed to clarify the mechanisms.

Predictive factors affecting the prognosis and late complications of 73 consecutive cases of esophageal atresia at 2 centers.

PURPOSE: While the diagnosis and outcomes of esophageal atresia (EA) have improved, associated anomalies, the management of late complications and growth remain major issues. We analyzed factors that affected the prognosis, late complications and growth. METHODS: We retrospectively reviewed EA patients treated at two centers from 1984 to 2016. Patient characteristics, complications (gastroesophageal reflux [GER], anastomotic stenosis, tracheomalacia, dysphagia) and growth were evaluated. RESULTS: Seventy-three EA patients were treated (overall survival rate:80.8%). The mean birth weight was 2514 ± 509 g in the surviving group, and 2453 ± 567 g in the fatal group excluded chromosomal abnormality (p = 0.76). Cardiac and chromosomal anomalies significantly affected mortality. Postoperative GER and anastomotic stenosis each occurred in 39% of the patients. Only GER was significantly affected by the Gross classification. The standard deviation (SD) values of the EA patients' growth were all lower than in the normal population. The SD of body weight was significantly lower in patients with extremity anomalies. CONCLUSIONS: Associated cardiac and chromosomal anomalies significantly affected the prognosis. GER and anastomotic stenosis were the most common late complications. The growth of the surviving cases was insufficient. These factors will help optimize the therapeutic strategies and postoperative management for EA.

Ghrelin stimulates intestinal adaptation following massive small bowel resection in parenterally fed rats.

BACKGROUND: Since short bowel syndrome (SBS) patients face life-threatening conditions, the development of therapeutic strategies to induce intestinal adaptation has been investigated. Ghrelin, a ligand of growth hormone (GH) secretagogue-receptor that stimulates the release of GH and insulin like growth factor-1 (IGF-1), has several pleiotropic effects. We investigated whether ghrelin induces intestinal adaptation in parenterally fed rats with SBS. METHODS: Sprague-Dawley rats underwent venous catheterization and were divided into 3 groups: those receiving 90% small bowel resection while leaving the proximal jejunum and distal ileum (90% SBR) with TPN (SBS/TPN group), those receiving 90% SBR with TPN + ghrelin (SBS/TPN/ghrelin group), and those receiving sham operation and fed chow (sham group). Ghrelin was administered intravenously at 10 µg/kg/day. On Day 13, the rats were euthanized and the small intestine harvested, and the histology and crypt cell proliferation rates (CCPR), apoptosis, and nutrient transporter protein levels were analyzed and the plasma hormones were measured. RESULTS: The villus height and crypt depth of the ileum in the SBS/TPN/ghrelin group were significantly higher than in the SBS/TPN group. The CCPR of the jejunum and the ileum significantly increased by the administration of ghrelin; however, the apoptosis rates did not significantly differ between the SBS/TPN and SBS/TPN/ghrelin groups. Significant differences did not exist in the plasma IGF-1 and nutrient transporter protein levels among three groups. CONCLUSIONS: The intravenous administration of ghrelin stimulated the morphological intestinal adaptation of the ileum to a greater degree than the jejunum due to the direct effect of ghrelin.

The bowel function and quality of life of Hirschsprung disease patients who have reached 18 years of age or older - the long-term outcomes after undergoing the transabdominal soave procedure.

BACKGROUND/PURPOSE: Hirschsprung disease (HD) is considered curable, but the postoperative bowel function is not always satisfactory. In this study, we evaluated the general condition, bowel function, and social performance in adults who were older than 17years of age who had undergone definitive operations in childhood. METHOD: From 1984 to 2016, 110 patients with HD underwent definitive surgery at our institute. Sixty-three patients who had undergone the transabdominal Soave procedure reached 18years of age. Their present status and symptoms, anorectal function, genitourinary function, and social performance were evaluated during the clinical follow-up via a questionnaire survey. RESULT: The mean age of the questionnaire respondents was 25.0 (19-37) years. The bowel function was mostly good. However, 56% of patients had abdominal pain more than once a week. Regarding evacuation symptoms, incontinence and soiling occurred in 18.7%. Among the respondents 33.3% were married, and 60% of those who were married had children. The respondents had achieved success in their education and professional careers. CONCLUSION: The bowel function of most patients was satisfactory, although some had chronic abdominal symptoms. Pediatric surgeons should continue trying to achieve complete bowel function after definitive surgery of HD. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: Level III.

Construction of a (18)F-FDG PET normative database of Japanese healthy elderly subjects and its application to demented and mild cognitive impairment patients.

OBJECTIVE: To construct a (18)F-FDG PET normative database of Japanese healthy elderly subjects and to apply it to demented and mild cognitive impairment (MCI) patients. METHODS: Seventy-seven Japanese normal volunteers from 41 to 84 years of age (36 males and 41 females) who underwent clinical, neuropsychological, and MRI examinations were selected. In these subjects, (18)F-FDG PET/CT scans were performed, (18)F-FDG PET images were analyzed using the 3D-SSP program, and a normative database for cerebral glucose metabolism was constructed. Then, (18)F-FDG PET images from 14 demented and MCI patients were evaluated based on the normative database. RESULTS: The 77 healthy elderly subjects were divided into three groups according to their age. In these subjects, the difference in glucose metabolism between males and females was minimal in contrast, glucose metabolism showed a weak reciprocal correlation with aging in several cerebral regions. The 3D-SSP images of 14 demented and MCI patients based on the age-matched (18)F-FDG PET normative database showed decreased patterns of glucose metabolism similar to those of previous studies on dementia diseases and MCI. CONCLUSIONS: An age-matched normative database can be applied to the evaluation of single subjects, and the application of a mixed database of males and females is viable. Normative databases are useful for detecting dementia diseases and their MCI.