Is colostomy closure without mechanical bowel preparation safe in pediatric patients? A randomized clinical trial.

BACKGROUND: Mechanical bowel preparation (MBP) is largely used worldwide prior to colostomy closure in children, although its benefits are questioned by scientific evidence, and its use can cause adverse reactions. We hypothesized that colostomy closure procedures in children are not associated with increased complications (surgical site infection [SSI] and anastomotic leakage) when performed without MBP. Thus, we conducted a noninferiority trial to compare the safety and efficacy of colostomy takedown with and without MBP. METHODS: A randomized noninferiority clinical trial was conducted at Hospital Infantil de Mexico in Mexico City from 2015 to 2019, in which the experimental group did not receive MBP prior to colostomy closure. A total of 79 patients were analyzed, and the primary outcomes were safety-related. Data were analyzed using the chi-squared test, Student's t-test, or Mann-Whitney U test as appropriate. RESULTS: The demographics in both groups were comparable. Statistical analysis revealed equivalence in safety outcomes (superficial SSI, 22.5% vs 15.3% p = 0.420; deep SSI, 7.5% vs 0% p = 0.081; reoperation, p = 0.320; intestinal occlusion, p = 0.986); no anastomotic leakage was observed in any group. Secondary outcomes such as fasting time and length of hospital stay after surgery were also similar between the groups. However, patients who received MBP were admitted 2 days before surgery. CONCLUSIONS: Our findings indicate that withholding MBP prior to colostomy takedowns in children is not associated with increased complications. Omitting MBP also leads to less discomfort and shortens hospital length of stay, suggesting that it has safer and more effective procedures. LEVEL OF EVIDENCE: Randomized controlled clinical trial with adequate statistical power.

Ganglioneuromatosis intestinal difusa a lo largo del tubo digestivo.

BACKGROUND: Ganglioneuromas are histologically benign neoplasms derived from the sympathetic nervous system, whose occurrence in the gastrointestinal tract is rare and often syndromic. According to the injury pattern and extension, lesions are divided into polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. This work aimed to present the incidental post mortem finding of diffuse ganglioneuromatosis of the gastrointestinal tract in a patient without syndromic involvement. CASE REPORT: We describe the case of a two-year-old female patient with surgically corrected type III tracheoesophageal atresia and fistulous recanalization, multiple episodes of aspiration pneumonia, and septic shock. During the last admission, she developed massive pulmonary hemorrhage and multi-organ failure. Post mortem histopathological study identified hypertrophy of the pylorus and enlarged enteric nerve trunks and plexuses with intermingled mature ganglion cells. We identified ganglioneuromatosis affecting all gastrointestinal tract segments with the predominance of the myenteric plexuses. CONCLUSIONS: Intestinal ganglioneuromatosis is a rare disease with a spectrum of lesions ranging from isolated to syndromic with high morbidity and mortality. Therefore, it is necessary to know the condition, investigate systematically when it is suspected, and rely on genetic studies to confirm or rule out any syndromic association.

INTRODUCCIÓN: Los ganglioneuromas son neoplasias histológicamente benignas derivadas del sistema nervioso simpático, cuya ocurrencia en el tubo digestivo es rara y comúnmente sindromática. De acuerdo con el patrón de la lesión y la extensión se dividen en ganglioneuroma polipoide, poliposis ganglioneuromatosa y ganglioneuromatosis difusa. El objetivo de este trabajo es presentar el hallazgo incidental post mortem de ganglioneuromatosis difusa del tubo digestivo en una paciente sin afectación sindromática. CASO CLÍNICO: Se describe el caso de un paciente de sexo femenino de 2 años con atresia traqueoesofágica tipo III corregida quirúrgicamente que cursó con recanalización fistulosa, múltiples episodios de neumonía por aspiración y choque séptico. Durante el último ingreso cursó con hemorragia pulmonar masiva y falla multiorgánica. En el estudio post mortem se identificó hipertrofia del píloro y de los troncos y plexos nerviosos entéricos con células ganglionares maduras entremezcladas. Se identificó ganglioneuromatosis que afectaba todos los segmentos del tubo digestivo, con predominio de los plexos mientéricos. CONCLUSIONES: La ganglioneuromatosis intestinal es una rara enfermedad que presenta un espectro de lesiones desde una forma aislada hasta sindromática con morbimortalidad elevada. Por ello, es necesario conocer la enfermedad, indagar sistemáticamente cuando se sospeche y apoyarse de estudios genéticos que confirmen o descarten alguna asociación sindromática.

Ganglioneuromatosis intestinal difusa a lo largo del tubo digestivo / Diffuse intestinal ganglioneuromatosis along the gastrointestinal tract

Resumen Introducción: Los ganglioneuromas son neoplasias histológicamente benignas derivadas del sistema nervioso simpático, cuya ocurrencia en el tubo digestivo es rara y comúnmente sindromática. De acuerdo con el patrón de la lesión y la extensión se dividen en ganglioneuroma polipoide, poliposis ganglioneuromatosa y ganglioneuromatosis difusa. El objetivo de este trabajo es presentar el hallazgo incidental post mortem de ganglioneuromatosis difusa del tubo digestivo en una paciente sin afectación sindromática. Caso clínico: Se describe el caso de un paciente de sexo femenino de 2 años con atresia traqueoesofágica tipo III corregida quirúrgicamente que cursó con recanalización fistulosa, múltiples episodios de neumonía por aspiración y choque séptico. Durante el último ingreso cursó con hemorragia pulmonar masiva y falla multiorgánica. En el estudio post mortem se identificó hipertrofia del píloro y de los troncos y plexos nerviosos entéricos con células ganglionares maduras entremezcladas. Se identificó ganglioneuromatosis que afectaba todos los segmentos del tubo digestivo, con predominio de los plexos mientéricos. Conclusiones: La ganglioneuromatosis intestinal es una rara enfermedad que presenta un espectro de lesiones desde una forma aislada hasta sindromática con morbimortalidad elevada. Por ello, es necesario conocer la enfermedad, indagar sistemáticamente cuando se sospeche y apoyarse de estudios genéticos que confirmen o descarten alguna asociación sindromática.

Abstract Background: Ganglioneuromas are histologically benign neoplasms derived from the sympathetic nervous system, whose occurrence in the gastrointestinal tract is rare and often syndromic. According to the injury pattern and extension, lesions are divided into polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. This work aimed to present the incidental post mortem finding of diffuse ganglioneuromatosis of the gastrointestinal tract in a patient without syndromic involvement. Case report: We describe the case of a two-year-old female patient with surgically corrected type III tracheoesophageal atresia and fistulous recanalization, multiple episodes of aspiration pneumonia, and septic shock. During the last admission, she developed massive pulmonary hemorrhage and multi-organ failure. Post mortem histopathological study identified hypertrophy of the pylorus and enlarged enteric nerve trunks and plexuses with intermingled mature ganglion cells. We identified ganglioneuromatosis affecting all gastrointestinal tract segments with the predominance of the myenteric plexuses. Conclusions: Intestinal ganglioneuromatosis is a rare disease with a spectrum of lesions ranging from isolated to syndromic with high morbidity and mortality. Therefore, it is necessary to know the condition, investigate systematically when it is suspected, and rely on genetic studies to confirm or rule out any syndromic association.

Functional outcome after cord detethering in fecally incontinent patients with anorectal malformations.

PURPOSE: Tethered cord (TC) occurs in 36% of patients with anorectal malformations (ARMs), for whom the benefit of detethering surgery remains unclear regarding bowel and/or bladder function. This study aimed to examine whether cord detethering could improve fecal and urinary incontinence in these patients. METHODS: This was a retrospective study of TC patients (>3 years old) with fecal incontinence and ARMs, who underwent detethering surgery between 2016 and 2020 and were followed up for at least 6 months. RESULTS: Of the 27 included patients, 55% had sacral ratios between 0.4 and 0.7, and in 37% it was < 0.4; the remaining 8% was over 0.7; 52% suffered from colonic hypermotility. After detethering surgery, partial fecal continence was achieved in five patients (18%); total fecal continence, in ten patients (37%); 12 (44%) remained fecally incontinent. Partial urinary continence was obtained in four cases (14%), and the number of patients with total urinary continence rose from 7 (25%) to 15 (55%). Lower extremity symptoms were also improved in 72% of the cases. Patients with colonic hypomotility were found to have a better functional outcome than those with colonic hypermotility (69% vs. 43%, respectively). CONCLUSION: Our study demonstrated that detethering surgery led to remarkably improved bowel and bladder control in ARM patients with fecal incontinence, which, surprisingly, was not associated with sacral ratio.

Predictive value of procalcitonin for intestinal ischemia and/or necrosis in pediatric patients with adhesive small bowel obstruction (ASBO).

PURPOSE: Evaluate serum procalcitonin (PCT) level as a predictor of intestinal ischemia or necrosis (IN) in patients with postoperative adhesive small bowel obstruction (ASBO). METHODS: Prospective cohort of consecutive patients with ASBO. Patients previously treated with antibiotics or septic were excluded. PCT was measured at the diagnosis of ASBO and every 24 h afterwards. MAIN OUTCOME: intestinal ischemia or necrosis (IN). RESULTS: Fifty-nine patients were included, 12 of whom were excluded; 47 patients remained in the study; male-to-female ratio = 1.9:1. MANAGEMENT: medical in 15 cases (32%) and surgical in 32 (68%). MAIN OUTCOME: Intestinal necrosis (IN) in 10 patients (21.3%). Mean PCT level was higher in patients with IN (15.11 ng/ml vs. 0.183 ng/ml, p=0.002), the proportion of patients with elevated PCT (>0.5 ng/dl) was higher in patients with IN (70% vs. 8.1%, p=<0.001, RR=26.4 with a 95% CI of 4.39-159.5). Elevated PCT levels at diagnosis had a 70% positive predictive value (PPV) and 91.8% negative predictive value (NPV) for prediction of IN. With a PCT value at diagnosis of >1.0 ng/dl, PPV was 87.5% and NPV, 92.3%. CONCLUSIONS: PCT levels are closely related to the presence of intestinal ischemia and necrosis in children with ASBO. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II.

Chylous Ascites in a Newborn with Gastroschisis. Case Report.

Chylous ascites is a rare disease, only two cases associated with gastroschisis have been published. We report a case treated conservatively with total parenteral nutrition (TPN) and octreotide. We reviewed the literature about management options for the chylous ascites.

[Efficacy of intestinal splinting in hostile abdomen secondary to postoperative flanges in pediatric patients]. / Utilidad de la ferulización intestinal (FI) en abdomen hostil secundario a bridas postoperatorias en pacientes pediátricos.

Objetivo: Mostrar la eficacia de la FI para prolongar el tiempo libre de oclusión intestinal quirúrgica en niños con abdomen hostil secundario a bridas posquirúrgicas. Método: Análisis retrospectivo de FI por abdomen hostil de 2000 a 2011 y su seguimiento a largo plazo. Comparamos el tiempo libre de oclusión quirúrgica antes y después de la FI. Resultados: Se incluyeron 20 FI en 19 pacientes. Predominaron las causas congénitas, la mediana de edad en la cirugía fue de 6 meses, todos tenían cirugías previas con mediana de tres, y dos de ellas fueron por oclusión intestinal previa. La férula se quitó a los 28 días (mediana). Con un seguimiento de 1-183 meses, hubo una recurrencia de oclusión quirúrgica. El tiempo libre de oclusión quirúrgica posferulización fue significativamente mayor que el preferulización mediante la prueba de Wilcoxon, con un valor Z = -3.594; p = < 0.0001. Conclusiones: Esta es la segunda serie exclusiva en niños que muestra que la FI es eficaz para prolongar el tiempo libre de oclusión quirúrgica.

Laparoscopic treatment of nonpalpable testicle. Factors predictive for diminished size.

PURPOSE: The purposes of this study were to demonstrate the usefulness of laparoscopy in intraabdominal testicle (IAT) and to determine factors associated with diminished size during the final outcome after laparoscopic orchidopexy. METHODS: This is a retrospective analysis of consecutive patients from 1999 to 2013 with a minimum follow-up of 1year. Patient and testicular factors were related to diminished size. RESULTS: Sixty one patients, and 92 testicles were included. Median age at operation was 42months. Initially we found 66 normal sized testes (71.7%), 22 hypotrophic (23.9%) and four atrophic (4.3%). Eighty seven testes were brought down laparoscopically, 50 in one surgical stage and 37 in two stages. Mean follow-up was 40.2months and the final outcome was success: 73.5% and diminished size: 26.5%. Variables associated with diminished size were hypotrophy during initial evaluation, short spermatic vessels, section of spermatic vessels, two-stage surgery and tension to reach contralateral inguinal ring. Multivariate analysis showed that initial hypotrophy (odds ratio [OR] 4.96, confidence interval 95% [CI] 1.36-18.10) and tension to reach contralateral ring (OR 4.11, 95% CI 1.18-14.34) were associated with diminished size. CONCLUSIONS: Laparoscopy is useful in treating IAT. Initial size and tension to reach contralateral ring are factors associated with diminished size.

[Prognostic factors related to mortality in newborns with necrotising enterocolitis]. / Factores pronóstico para mortalidad en neonatos con enterocolitis necrosante.

BACKGROUND: Necrotizing enterocolitis is the most frequent and severe acquired gastrointestinal disease in newborns and still has high mortality. There are few published papers about prognostic factors of death in our country. OBJECTIVE: To know the factors associated with death in patients with necrotizing enterocolitis. METHODS: Retrospective, descriptive, comparative study with a case-control design was conducted on patients with necrotizing enterocolitis during a 5-year period. RESULTS: Deceased patients had significantly lower platelet counts compared to survivors (P=0.022) and the prognostic factors associated with mortality were anaemia (P=0.006, OR = 15.62), stage III of necrotizing enterocolitis (P<0.001, OR = 47.5), to require surgical treatment (P<0.001, OR = 47.5), to have intestinal necrosis (P=0.001, OR = 48.5) or perforation (P=0.016, OR =24.25), to have medical complications, specifically intravascular disseminated coagulation (P<.001, RR = 98), and multi-organ failure (P<0.001, RR = 2). It was also found that patients with gastrointestinal symptoms and diagnosis of necrotising enterocolitis when they were hospitalized were more likely to have surgical treatment. CONCLUSIONS: We must be aware of the factors associated with mortality, as well as those associated with surgical treatment to reduce overall mortality for this condition.

[Prognostic factors related to mortality in newborns with jejunoileal atresia]. / Factores pronóstico para mortalidad en neonatos con atresia intestinal yeyuno-ileal.

BACKGROUND: Jejuno-ileal atresia is one of the main causes of intestinal obstruction in neonates. The origin is vascular accidents in the fetal intestine. It is an entity that requires early and specialist management. OBJECTIVE: to know the factors related to mortality in neonates with jejunoileal atresia. METHODS: Case-control nested in a cohort design, comparative study during ten years, between deceased and survivors analyzing factors related to mortality before surgery and during surgery and in the postoperative course. RESULTS: We analyzed 70 patients in 10 years, there were 10 deaths (14.2%). No one had a prenatal diagnosis. Factors related to mortality were: intestinal perforation with a relative risk (RR) of 4.4, peritonitis (RR: 5.6), the need of stomas (RR: 4.9), the presence of sepsis (RR: 4.6) and when the residual small bowel length was below 1 meter (RR: 7.4). CONCLUSION: The delay in diagnosis causes late intervention and increased mortality delayed diagnosis promotes late transport of the neonate and enhances mortality, factors associated with mortality related to intestinal perforation. It is necessary to spread this disease in the medical community to improve prenatal and postnatal diagnosis.