Risk factors analysis for clinical symptoms of prenatally diagnosed choledochal cysts: a retrospective study.

BACKGROUND: This study aimed to screen the impact factors for clinical symptoms of prenatally diagnosed choledochal cysts (CDCs), to warn about the occurrence of clinical symptoms and the timing of surgery. METHODS: Medical records of patients with prenatally diagnosed CDCs admitted to our hospital from April 2013 to April 2018 were retrospectively reviewed. Fetal hilar or abdominal cysts were found by prenatal ultrasonogram. All patients underwent laparoscopic cyst excision and hepaticojejunostomy in our center. Univariate analysis and multivariate logistic regression analysis were performed to screen the factors related to clinical symptoms intimately. RESULTS: Two hundred eighteen cases were included. One hundred thirty-four patients (134/218, 61.5%) presented clinical symptoms before surgery. The results of univariate analysis showed that patients with clinical symptoms had earlier time of prenatal diagnosis (P = 0.002), higher values of GGT, TBIL, DBIL (P < 0.001, P < 0.001, P < 0.001, respectively) and larger maximum diameter of cyst before surgery (P = 0.012). Multivariate logistic regression analysis suggested that the time of prenatal diagnosis (P = 0.001, OR = 0.898, 95% CI: 0.845 ~ 0.955) and the GGT value within one week of life (P = 0.028, OR = 1.002, 95% CI: 1.000 ~ 1.003) were independent influencing factors for symptoms. CONCLUSIONS: For children with prenatally diagnosed CDCs, approximately 2/3 patients presented noticeable clinical symptoms before surgery. The time of prenatal diagnosis and the GGT value within 1 week of life were independent impact factors for the occurrence of clinical symptoms.

Prenatal diagnosis at different gestational times and clinical features of choledochal cysts: a single tertiary center report.

PURPOSE: This study aimed to evaluate the effect of prenatal diagnosis at different gestational times on the clinical features of patients with choledochal cysts (CDCs). METHODS: Medical records of patients with prenatally diagnosed CDCs admitted to our hospital (April 2013-April 2018) were retrospectively reviewed. The clinical characteristics and pathological CDC features were analyzed. RESULTS: Two hundred eighteen cases were included. Patients were divided into two groups. Group 1 and group 2 had a prenatal diagnosis at ≤ 27 weeks of gestation (second trimester of gestation, n = 157) and > 27 weeks (third trimester of gestation, n = 61), respectively. The incidence of jaundice and the TBIL, IBIL and GGT levels were higher in Group 1 (P = 0.021, P = 0.029, P = 0.042, P = 0.007, respectively). The maximum cyst diameter at the time of surgery was larger in Group 1 (P = 0.015). An association study showed that the time of prenatal diagnosis was negatively correlated with the maximum cyst diameter both postnatally (r = - 0.223, P = 0.001) and at the time of surgery (r = - 0.268, P < 0.001). CONCLUSION: Unlike patients diagnosed at a late prenatal age, patients diagnosed at an early prenatal age tend to present clinical symptoms (jaundice, manifested as high indirect bilirubin), hepatic function damage, and large cysts at the time of surgery.

Pattern of anatomic disorder and surgical management of anorectal prolapse in anorectal malformation.

AIM: Due to the paucity of data and controversy regarding the etiology and surgical approach for managing anorectal prolapse (ARP) after anorectoplasty, we sought to investigate the underlying anatomic disorder and the surgical outcome in managing this challenging complication. METHODS: We performed a retrospective study on 83 patients with ARP related to anorectal malformations (ARM). Logistic regression analyses were performed to detect the risk factors for the ARP severity. Surgical procedures were stratified according to identified anatomical abnormalities and surgical outcomes were analyzed. RESULTS: 50 patients (62.7%) had high-type ARM. The original anorectoplasty had a higher rate of ARP in laparoscopic-assisted anorectoplasty (n = 49, 59.0%) versus posterior sagittal anorectoplasty (n = 11, 13.3%). ARP was associated with rectal fat hyperplasia (67.5%), dilated muscular tunnel (79.5%), longitudinal muscle (LM) discontinuity (16.9%), rectal dilation (22.9%), mislocated anus (7.2%), and excessive mobile mesorectum (3.6%). Based on the ARP severity, the patients were divided into a severe group (Group 1, n = 38) and a moderate group (Group 2, n = 45). Binary logistic regression analysis showed that hyperplasia rectal fat (OR 4.55, 95% CI 1.16-17.84), rectal dilation (OR 4.21, 95% CI 1.05-16.94), and high-type ARM (OR 2.90, 95% CI 1.14-7.39) were independent risk factors for the development of severe ARP. Complications after stratified surgical repair included wound infection in six patients (7.2%), anal stenosis in one patient (1.2%), and ARP recurrence in two patients (2.4%). Twenty-six patients without colostomy before prolapse repair were followed up for 2 to 12 years. All the patients maintained voluntary bowel movements. Following ARP repair, there was an overall higher rate of no soiling or grade 1 soiling (88.5 vs. 65.4%), but 3 of 12 patients with grade 2 constipation were upgraded to grade 3. CONCLUSION: Our study shows that ARM-related anorectal prolapse is associated with excessive rectum, hyperplasia of rectal fat, mobile mesorectum, loose muscular tunnel, LM discontinuity, and anal mislocation. Surgical repair with techniques stratified according to the patients' underlying risk factors is effective to prevent recurrence and improve the soiling continence.

A novel combined enteroscopy and laparoscopy approach to prevent urethral complications in management of rectourethral fistula.

BACKGROUND: For the last 20 years, laparoscopy management of anorectal malformations (ARM) has been challenged due to the development of postoperative urethral diverticulum or injury caused by the imprecise transection of rectourethral fistulae, particularly rectobulbar fistulae situated deep in the pelvis. We have developed a combined approach of enteroscopy and laparoscopy for intraluminal incision of a rectourethral fistula. METHODS: We retrospectively reviewed 47 ARM patients who underwent surgical corrections using the combined approach between January 2019 and June 2020. Early postoperative and subsequent follow-up results were evaluated. RESULTS: The median follow-up period was 12 months. The average age at surgery was 3.18 ± 0.64 months. The mean operative time of a single-incision laparoscopic-assisted anorectoplasty (SILAARP) was 1.19 ± 0.29 h. The time for intraluminal incision of the fistula was shortened from 14 to 2 min. No patients underwent a conversion. The average postoperative hospital stay, time to full feeds and placement of an anal tube were 10 days, 1 day, and 5 days, respectively. No urethral diverticulum, urinary injury, wound infection, rectal retraction, anal stenosis or rectal prolapse was encountered in the cohort. CONCLUSIONS: The combined enteroscopy and laparoscopy approach offers precise management of rectourethral fistulae. It could effectively obviate urethral complications, eliminating the obstacles of laparoscopy application in the management of ARMs.

Refinements in surgical techniques for visualized tunnel formation in laparoscopic-assisted anorectoplasty.

PURPOSE: Laparoscopic-assisted anorectoplasty (LAARP) is becoming a more popular procedure for anorectal malformation (ARM) repair. However, the conventional technique for creating pull-through tunnel between the perineal skin and the pelvic floor has been criticized as being semi-blind. This study aims to present a refined version of our previously reported clamp introduction technique for visualized tunnel formation in the center of the sphincter muscle complex (SMC) for rectal pull- through for ARMs. METHODS: A retrospective review was performed for ARM patients who underwent LAARP from Jan 2019 to Jun 2020. Longitudinal muscle tube (LMT) tunnel was created using the clamp-dilator introduction technique: a laparoscopic dilator was used to create a pelvic tunnel within LMT in high ARM, and the clamp introduction under the direct vision technique was performed for creating the perineal tunnel of LMT for both high and intermediate ARMs. RESULTS: Seventy patients (1-198 days) with high-type (27cases) and intermediate-type (43 cases) ARM underwent LAARP using clamp-dilation introduction technique. No patients suffered from urinary tract injury, recurrent rectourethral fistula, urethral diverticulum and urinary incontinence. One patient suffered from wound infection and rectal retraction which required a redo pull-through on postoperative day 7. Rectal prolapse requiring surgical intervention developed in one patient. Postoperative MRI examination confirmed central placement of the rectum within the LMT in all cases. CONCLUSION: Our experience demonstrates that a visualized tunnel formation in the LMT center can be achieved by the clamp-dilator introduction technique in LAARP for both high and intermediate ARMs.

Normal anorectal musculatures and changes in anorectal malformation.

PURPOSE: We investigated the anorectal musclulature in normal children and anorectal malformations (ARM) to evaluate its role in bowel control mechanism. METHODS: Pelves of 50 neonates died of ARM-unrelated diseases and 16 patients with anorectal malformations (8 high, 5 intermediate, and 3 low ARMs) were dissected and analyzed. RESULTS: Normal anorectal musculature was divided into three muscular tubes: the internal sphincter tube (IAST), longitudinal muscle tube (LMT) and transverse muscle tube (TMT). The LMT came from the outer longitudinal smooth muscle fiber of the rectum and the striated muscle fiber of the levator ani, and the TMT composed of the puborectalis and the external anal sphincter. However, in ARM, the IAST was absent and the LMT, the center of the sphincter muscle complex, was only from the levator ani and could be divided into the pelvic portion and the perineal portion. The former, from the upper rim of the puborectalis to the bulbar urethral, became narrowed and dislocated anteriorly near to the posterior urethra in high ARM and rectal pouch in intermediate ARM. The latter, below the bulbar urethra to the anal dimple, was fused to a column both in high and intermediate ARM. The columnar perineal LMT run downwards and then split, penetrated the superficial part of EAS and terminated at the deep aspect of the skin, to form the anal dimple, which represents the center of the perineal LMT from the perineal aspect. The length of the LMT was longer in high and intermediate ARM than the normal neonate. The columnar perineal LMT and narrowed pelvic LMT could be possibly identified by laparoscopic and perineal approaches retrospectively and widened to allow the passage of the rectum through. CONCLUSIONS: The anorectal musculature in ARM is composed of agenesic LMT and TMT and the narrowed LMT gives anatomical evidence of the center, where the neorectum should pull through.

Laparoscopic-assisted anorectoplasty for intermediate type rectovestibular fistula: a preliminary report.

PURPOSE: Laparoscopic-assisted anorectoplasty (LAARP) is considered to benefit the male patients with anorectal malformation (ARM). This study evaluates LAARP management for intermediate type rectovestibular fistula (IRVF) in the female patient with ARM. METHODS: Twelve patients with IRVF (aged 3-5 months) underwent LAARP from 2017 to 2019 in our institute. LAARP was performed for mobilization of the rectum, visualization and enlargement of the center of the sphincter muscle complex (SMC) from pelvic and perineal aspects, intra-fistula mucosectomy and rectal pull-through in the SMC with the fourchette and the perineal body unattached. RESULTS: LARRP was performed in all patients without conversion to open procedure. No patient suffered from wound infection, vaginal injury, recurrent fistula and anal stenosis. The parents were satisfied with the appearance of the wound. Rectal prolapse developed in one patient and needed surgical correction. The patients were followed up for a mean of 19.7 months (ranged from 12 to 35 months). CONCLUSION: Our preliminary experience shows that LAARP offers an alternative method of correction for the IRVF with good visualization of the SMC and may diminish the risks of wound dehiscence and vaginal injury.

Laparoscopic surgical technique to enhance the management of anorectal malformations: 330 cases' experience in a single center.

PURPOSE: Laparoscopic-assisted anorectoplasty (LAARP) is considered to benefit the patients with vesico-prostatic fistula. The aim of this study is to present the details of our LAARP technique for improving the short- and long-term outcomes in the patients with high and intermediate types of anorectal malformations (ARMs). METHODS: 330 patients with high-type (174 cases) and intermediate-type (156 cases) anorectal malformation (aged 8 days to 15 years) underwent LAARP from 2001 to 2019. LAARP was performed for full mobilization and resection of the dilated rectum, intra-rectal closure of the fistula, visualization, and enlargement of the center of the longitudinal muscle tube (LMT) from pelvic and perineal aspects. RESULTS: LAARP was performed in all patients and no patient was converted to open procedure. The urethral diverticulum was found in three patients (1.02%, 3/294) according to postoperative protocol voiding cystourethrogram but was not associated with any symptoms such as urinary tract infection and dysuria. Rectal prolapse requiring surgical intervention developed in 25 (7.6%) of 330 patients. Anal stricture occurred in three patients and re-do anoplasty was performed 5 months after LAARP. Anal retraction occurred in two patients and re-pull-through was conducted at 5 and 6 days, respectively, after LAARP. 228 patients who were older than 3 years were followed up. The median follow-up period was 5.8 years (range 3-15 years). 217 patients (95.2%) had voluntary bowel movements; 202 patients (88.6%) were free from soiling or with grade 1 soiling; 30 patients (13.6%) and 25 patients (11.3%) suffered from grade 1 and grade 2 constipation, respectively, while no patient had grade 3 constipation. CONCLUSION: Our experience demonstrates that the LAARP has advantages on rectal mobilization and resection, intra-rectal fistula closure and accurate tunnel formation in the LMT with minimal trauma. The improvement of the short-term and long-term outcomes after LAARP has been shown not only for high-type ARM but also for intermediate-type ARM.

[Transumbilical single-site single-port versus single-site double-port laparoscopic varicocelectomy for varicocele in adolescents].

OBJECTIVE: To compare the effect of transumbilical single-site single-port with that of transumbilical single-site double-port laparoscopic varicocelectomy in the treatment of varicocele in adolescents. METHODS: We randomly assigned 80 varicocele patients aged 10 - 16 years to two groups of equal number to receive transumbilical single-site single-port and single-site double-port laparoscopic varicocelectomy, respectively. We compared the operation time, postoperative hospital stay, incisional pain, complications and satisfaction with the abdominal cosmetic outcomes between the two groups. RESULTS: All the operations were successfully performed. The double-port group showed a significantly higher score on the Visual Analogue Scale than the single-port group (4.8 +/- 1.4 vs 3.6 +/- 1.1, t = -4.986, P < 0.01), but there were no significant differences between the two groups in the operation time ([29.8 +/- 4.2] vs [31.2 +/- 4.6] min, t = 1.383, P = 0.171), postoperative hospital stay ([1.95 +/- 0.7] vs [1.82 +/- 0.8] d, t = -0.784, P = 0.436), complications (0 vs 0) and scores on the satisfaction with abdominal cosmetic outcomes (4.6 +/- 0.6 vs 4.8 +/- 0.5, t = 1.253, P = 0.214). No recurrence, umbilical hernia, hydrocele and orchiatrophy were found in the two groups of patients at 6 months after operation, and no visible scar was observed on the abdominal surface. CONCLUSION: With strict surgical indications, single-site single-port and single-site double-port laparoscopic varicocelectomies have similar clinical effects in the treatment of varicocele, which leave no scar on the abdominal surface. Single-site double-port laparoscopy needs no special instruments and therefore is worthier of wide clinical application.

Transurachal Catheter for Management of Difficult Catheterization in Anorectal Malformations: A Novel Technique.

BACKGROUND: Urinary tract drainage is necessary to facilitate the maneuver in laparoscopic-assisted anorectoplasty (LAARP). Male patients with Anorectal malformations (ARM) are often encounter difficult catheterization during surgery. OBJECTIVE: We pioneered the urinary catheterization through the urachus in ARM patients and evaluated the efficacy. METHOD: Fourteen ARM patients undergoing urinary catheterization through urachus between September 2015 and September 2023 were reviewed. RESULTS: The median age at the time of surgery was 0.06 months. Nine neonatal patients underwent the one-stage LAARP, while five patients underwent staged procedure. Four ARM patients with rectoprostatic fistula, while ten with rectobulbar fistula. All patients successfully underwent transurachal catheterization. No incidents of catheter blockage, accidental removal, or urinary tract infection symptoms were detected during hospitalization. CONCLUSIONS: Transurachal catheterization is a safe, effective, and cosmetic procedure for ARM patients with difficulty urethral catheterization. LEVEL OF EVIDENCE: IV.

Efficacy of Laparoscopic Management of Posterior Urethral Diverticulum in Anorectal Malformations.

BACKGROUND: A posterior urethral diverticulum (PUD) is a serious postoperative complication after anorectal malformation correction. Complete resection is technical demanding because of limited retrourethral working space deep in the pelvis. OBJECTIVE: We pioneered the single-incision laparoscopic approach for PUD excision and evaluated the efficacy. DESIGN, SETTING, AND PARTICIPANTS: Twenty-six PUD patients undergoing redo surgeries between June 2011 and June 2021 were reviewed. SURGICAL PROCEDURE: A series of transabdominal retraction sutures were placed through the PUD to facilitate dissection. The contents were evacuated to create a working space. Distal PUD dissection was carried along the submucosal layer to prevent injury of the urethra/pelvic nerve complex. The rectal mucosa was peeled off from the junction site for complete PUD excision. The muscular cuff of the distal rectum was then oversewn. MEASUREMENTS: Operative time, postoperative recovery, and complications were assessed. RESULTS AND LIMITATIONS: The mean age of redo surgery was 2.46 yr. The average operative duration was 2.35 h. The mean postoperative hospital stay, resumption of full diet, and bowel movement were 10.23, 2.15, and 1.54 d, respectively. The median follow-up period was 46 mo (12-132 mo). No remnant of PUD, recurrent fistula, or urinary leak was detected. None of the patients had difficulty in urination, urinary dribbling, urinary tract infection, constipation, or soiling. All patients retained morning erection, and two postpubertal patients had ejaculations. CONCLUSIONS: Our single-incision laparoscopic redo surgery provides an effective approach for PUD excision. It minimizes complications. It also preserves urinary and bowel continence and sexual function. PATIENT SUMMARY: Complete resection of a posterior urethral diverticulum (PUD) in anorectal malformation is technically demanding because of limited retrourethral working space in the deep pelvis. The outcomes of single-incision laparoscopic PUD excision were satisfactory.

Laparoscopic-assisted anorectoplasty for anorectal malformation with rectobulbar fistula: A two-center comparative study with posterior sagittal anorectoplasty.

Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula (RBF), this study aimed to compare the outcomes of LAARP and posterior sagittal anorectoplasty (PSARP) for ARM with RBF. Demographic data, postoperative complications, and bowel function of RBF patients who underwent LAARP and PSARP at 2 medical centers from 2016-2018 were retrospectively reviewed. Eighty-eight children with RBF were enrolled, including 43 in the LAARP group and 45 in the PSARP group. There were no significant differences in the sacral ratio (P = .222) or sacral agenesis (P = .374). Thirty-seven and 38 patients in the LAARP and PSARP groups were followed up for a median of 4.14 years. The postoperative complications were comparable between the groups (P = .624), with no cases of urethral diverticulum. The urination of all cases was normal and no evidence of cyst formation was found on MCU or MRI during the follow-up period. The incidence of rectal prolapse was similar between the 2 groups (9.3% vs 17.8%, P = .247). The groups had equivalent Bowel Function Score (15.29 ± 2.36 vs 15.58 ± 2.88, P = .645), but the LAARP group had better voluntary bowel movement (94.6% vs 84.2%, P = .148) by Krickenbeck classification. The intermediate-term outcomes of LAARP show that the urethral diverticulum was rare by the intraluminal incision of the fistular and the bowel function was comparable to that of PSARP in ARM with rectobulbar fistula. However, LAARP was associated with smaller perineal wounds.

Laparoscopic-Assisted Anorectoplasty for Rectovestibular Fistula: A Comparison Study with Anterior Sagittal Anorectoplasty.

BACKGROUND: Posterior or anterior sagittal anorectoplasty (ASARP) is the mainstream for correcting rectovestibular fistula (RVF). However, the intermediate RVF has the potential risk of wound complications when applying ASARP due to its high rectal pouch, long fistula tract, and difficulty separating the rectum and vagina. We developed laparoscopic-assisted anorectoplasty (LAARP) for surgical correction of RVF, which has acceptable preliminary outcomes. The purpose of this study is to evaluate the safety and efficacy of LAARP in comparison with ASARP for patients with RVF. MATERIALS AND METHODS: Twenty-five patients with RVF who underwent LAARP between October 2017 and December 2020 were retrospectively reviewed. The outcomes were compared with 43 patients who underwent ASARP between April 2015 and August 2018. The age, weight at operation, sacral ratio, operative time, and postoperative hospital stay were evaluated. The results were assessed for complications, perineum appearance, and bowel function. RESULTS: The two groups were comparable in terms of demographics. The median operative time of the LAARP group was significantly longer than that of the ASARP group (113 vs. 95 minutes; p = 0.015). The mean length of the resected rectum in the LAARP group was also longer than that in the ASARP group (6.75 ± 5.07 vs. 3.31 ± 3.06 cm; p = 0.001). Compared with the LAARP group, complications in the ASARP group were more frequent (4.0 vs. 27.9%, p = 0.036). No intraoperative or postoperative wound-related complications occurred in the LAARP group. However, in the ASARP group, one patient had an intraoperative vaginal injury and four had postoperative anastomosis-related complications. The incidence of redo operation in the ASARP group was significantly higher than that in the LAARP group (p = 0.000). Cosmetic satisfaction was higher in the LAARP group (96.0 vs. 76.7%; p < 0.05). In terms of voluntary bowel movement, soiling, and constipation, the LAARP group had similar results compare with the ASARP group. CONCLUSION: The LAARP technique has shown several unique strengths in treating intermediate type RVF, including lower risks of complications, and minimal muscular injury, with a comparable bowel function.

One-stage versus staged laparoscopic-assisted anorectoplasty for high-and intermediate anorectal malformations: Medium-term outcomes from a propensity score matching analysis.

BACKGROUND: The timing of anorectoplasty for anorectal malformations (ARMs) is controversial and essential for long-term bowel function. The advantages of laparoscopy make primary anoplasty possible for neonates. This study aims to report the medium-term results of the one-stage laparoscopic-assisted anorectoplasty (LAARP) and compare them with the staged LAARP. METHODS: This study included 242 boys who underwent LAARP between June 2013 and December 2018 in our center. Forty-five neonatal patients successfully underwent the one-stage LAARP, and the remaining 197 patients who had already undergone colostomy received staged procedures. The complications and bowel function were compared between the two groups after 1:1 propensity score matching (PSM). RESULTS: Before matching, age at assessment and classification were significantly different between the two groups (P < 0.05). After PSM, 42 patients were included in each of the two groups, and the patients were well balanced. The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group (P < 0.05). The median follow-up periods were 55.0 and 54.5 months, respectively. The mean value of BFS was similar in the two groups. After medical management, a second evaluation was conducted to distinguish overflow pseudo-incontinence from patients with no bowel control potential. The functional outcome in the two groups is comparable (P = 0.307). CONCLUSIONS: One-stage LAARP is safe and feasible for neonates with high-and intermediate-type ARMs. Compared with staged LAARP, one-stage LAARP has fewer complications and comparable functional outcomes. The authors recommend these procedures to be performed in dedicated centers with sufficient expertise. LEVEL OF EVIDENCE: Level III.

Spleen-preserving proximal splenic-left intrahepatic portal shunt for the treatment of extrahepatic portal hypertension in children.

PURPOSE: The Rex shunt has been employed successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of the internal jugular vein. The authors describe a novel adaptation of spleen-preserving spleno-Rex bypass, successfully carried out in children with extrahepatic portal hypertension. METHODS: The mean age of the four patients (1 boy, 3 girls) was 46 months at the time of operation. All children had a history of upper gastrointestinal bleeding, and suffered from splenomegaly and hypersplenism. Spleen-preserving proximal splenic-left intrahepatic portal shunt was performed in all patients. The splenic artery and vein were ligated at the splenic hilum, and the splenic vein was completely separated from the bed of the pancreas to its junction with the inferior mesenteric vein. The freed splenic vein was anastomosed to left portal vein. The short gastric and left gastroepiploic vessels were kept intact to supply and drain the spleen. All patients were followed-up for 7-33 months (median: 21.5 months). RESULTS: The spleen-preserving spleno-Rex bypass was successfully performed in all 4 patients. The median operative time was 225 min (range: 215-260 min). One patient received blood transfusion, and the postoperative length of hospital stay varied from 4 to 6 days (median: 4.5 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized and the biochemistry tests were within normal range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the proximal splenic-portal shunt in each patient. The size of the spleen decreased and there was no recurrence of variceal bleeding. CONCLUSIONS: The spleen-preserving spleno-Rex bypass is a viable option to treat EHPVO in children.

Single-incision laparoscopic excision of pancreatic tumor in children.

PURPOSE: Single-incision laparoscopic surgery (SILS) as a surgical approach in treatment of pancreatic disease has recently been reported in adults. However, its application in pancreatic surgery in children is limited. In this article, we report our preliminary experience of SILS in children with pancreatic disease. METHODS: Three children with pancreatic tumor underwent single-incision laparoscopic partial pancreatectomy between July 2011 and August 2013. Two of three children were girls, and one was a boy. The ages ranged from 2 to 10 months, with an average age of 6.7 months. RESULTS: All operations were successfully performed. There was no conversion to the conventional multi-incision surgery. The mean operation time of the 3 cases was 153.3 minutes (range 120-200 minutes). The postoperative hospital stay was 7 days. The drainage tubes were kept for 3 to 4 days after surgery. There was no pancreatic juice leak in this case series. All patients were followed up and there was no recurrence. CONCLUSIONS: Single-incision laparoscopic partial pancreatectomy for children with pancreatic tumor is feasible.

Long term outcomes of laparoscopic-assisted anorectoplasty: a comparison study with posterior sagittal anorectoplasty.

PURPOSE: The aim of this study is to compare the long term outcomes between laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for children with rectobladderneck and rectoprostatic fistula anorectal malformations (ARM). METHODS: Thirty-two ARM children with rectobladderneck and rectoprostatic fistula who underwent LAARP between October 2001 and March 2012 were reviewed. The outcomes were compared with those of 34 ARM children who underwent PSARP between August 1992 and September 2001. The sacral ratio (SR), age at operation, operative time, postoperative hospital stay and complications were evaluated. Bowel functions were assessed using the Krickenbeck classification. RESULTS: The mean operative time of the LAARP was significantly shorter than that of PSARP group (1.62 ± 0.40 vs 2.13 ± 0.30 h). The postoperative hospital stay was significantly shorter in the LAARP group (5.8 ± 0.65 vs 8.4 ± 0.67 h). The wound infections (11.8% vs 0%) and recurrent fistula (11.8% vs 0%) were more common in PSARP patients. Th e overall morbidity rate of PSARP group was significantly higher than that of the LAARP group (35.3% vs 12.5%, p<0.05). However, 7.5% of the LAARP patients developed rectal prolapse. Twenty-four of 32 patients were followed up for more than 3 years in LAARP group. The median follow up period was 7.5 years (range 4-11) in LAARP patients and 15.5 years (range 11-20) in PSARP patients. The rates of voluntary bowel movement, soiling (grade 1, 2 & 3) were similar in both groups. More patients from PSARP group developed grade 2 or 3 constipation (22.5% vs 0%, P<0.01). CONCLUSIONS: Compared to PSARP, LAARP is a less invasive procedure. The long term functional outcomes after LAARP were equivalent if not better than those of PSARP.

Transanal rectal mucosectomy and partial internal anal sphincterectomy for Hirschsprung's disease.

PURPOSE: Hirschsprung-associated enterocolitis (HAEC) is a serious complication of Hirschsprung's disease (HD), with generalized sepsis and high mortality rate. Although the surgical correction of HD is mostly successful, challenges remain in the management of children with repeated episodes of enterocolitis. The authors describe a novel modification of transanal rectal mucosectomy and partial internal anal sphincterectomy (TRM-PIAS) for HD. METHODS: One hundred twenty-seven HD children aged from 8 days to 16 years who successfully underwent TRM-PIAS were reviewed. TRM-PIAS was carried out circumferentially along the anorectal line. Anterior dissection was conducted between the rectal submuscosal layer and the rectal muscular sleeve. The posterior dissection was performed along the plane between internal and external anal sphincters. Normal colon was pulled through and anastomosed to anal mucosa. Aganglionic segment, rectal mucosa, part of internal anal sphincter and posterior rectal muscular cuff were removed. Twenty-five age-matched children without defecation dysfunction were used as the control group in the study of anal resting pressure. RESULTS: Patients were followed up for 6-12 years (median: 8.2 years). The median age at last follow-up was 12.2 years (7.2-20.1 years). The incidence of enterocolitis decreased from 33.9% (43/127) preoperatively to 1.6% (2/127) postoperatively (P<0.01). The incidence of constipation decreased from 100% (127/127) preoperatively to 2.4% (3/127) postoperatively (P<0.01). Soiling rate on postoperative 1 month was 32.3%. It gradually decreased to 1.6% 6 months later. Anorectal manometries showed that mean anal resting pressure was significantly reduced from 37.9±12.5 mm Hg preoperatively to 20.2±6.4 mm Hg on postoperative 1 month and 24.8±9.9 mm Hg on postoperative 6 months, which were similar to age-matched normal controls (27.9±9.6 mm Hg, P>0.05). CONCLUSIONS: TRM-PIAS is effective in treatment of HD. It is associated with low postoperative HD-associated enterocolitis.

Laparoscopic pancreaticojejunostomy for pancreatic ductal dilatation in children.

PURPOSE: The application of laparoscopic surgery in pancreatic surgery in children is limited. In this article, we describe laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation. METHODS: Four children with recurrent pancreatitis and pancreatic ductal dilatation underwent laparoscopic pancreaticojejunostomy between July 2009 and November 2011. Longitudinal incision of the dilated pancreatic ducts and side-to-side Roux-Y pancreaticojejunostomy were performed. RESULTS: Operative time ranged from 103 to 154 min, and blood loss was minimal. The average postoperative hospital stay was 4 to 6 days. There were no pancreatic leaks. None of the patients experienced recurrence of pancreatitis. CONCLUSIONS: Laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation is safe and effective.

Gastroportal shunt for portal hypertension in children.

PURPOSE: Extrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension. METHODS: The mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months). RESULTS: The gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding. CONCLUSIONS: The gastroportal shunt is an effective treatment of extrahepatic portal hypertension.