Tubularized Gastric Conduit is More Desirable in Pediatric Patients Treated with Minimally Invasive Esophagectomy and Gastric Pull-Up.

INTRODUCTION: Conditions requiring an esophagectomy and esophageal replacement are rare in children. The preferred method and ideal replacement organ continue to be debated. We present long-term outcomes in children treated with esophagectomy and gastric pull-up. METHODS: We conducted a retrospective review of all the patients who underwent a esophagectomy and gastric pull-up at two major pediatric institutions from 2004 to 2015. Follow-up data were obtained for children when available, including any postoperative complications, need for dilation of strictures, and current feeding method. RESULTS: Minimally invasive procedures were performed on 7 patients (5 female and 2 male) with a median age of 3 years (range 2-20, standard deviation = 8). Three patients successfully underwent laparoscopic transhiatal esophagectomy and cervical gastric pull-up, and three patients successfully underwent combined laparoscopic and right thoracoscopic (Ivor-Lewis) esophagectomy and cervical gastric pull-up. We identified an additional 3 patients who had an open esophagectomy and gastric pull-up. Seven patients had tubularized gastric conduits, six without pyloroplasty and one with pyloroplasty. For those patients with tubularized conduits, the average time to achieve full oral feeds was 16 days, with 1 patient with pyloroplasty who took 27 days. Of the three whole-stomach conduits, one reached oral independence at 19 days and the other two had yet tolerated anything per os. Follow-up data were available for all patients. At the average 5 years follow-up (ranging from 1 month to 7 years), all but two were thriving well with full oral feeds. CONCLUSIONS: Minimally invasive esophagectomy and gastric pull-up is a good alternative in managing pediatric patients in need of esophagectomy and replacement; it offers acceptable early and long-term outcomes. Tubularized conduit appears to be superior to using the whole stomach and potentially avoids pyloroplasty. Ongoing study is needed to validate our findings.

Genetic determinants influencing the response to injury, inflammation, and sepsis.

The genetic background has recently been recognized as an important element in the response to injury, contributing to the variability in the clinical outcome of critically ill patients. The traditional approach to studying the genetic contribution requires the availability of families with multiple members who have experienced similar disease conditions, a situation that is nearly impossible to find in the case of trauma. Association studies looking at unrelated individuals across populations require large economic and labor-intensive efforts. Thus, a candidate gene approach has been the sole methodology used to correlate genetic variability with clinical outcome. However, this approach cannot provide a comprehensive description of a multigenic condition. Animal models are an alternative for studying the genetic contributions to variability in the response to injury. A murine model is ideal because a large set of inbred strains are available; congenic, consomic, transgenic, and recombinant strains can also be used. Employing this paradigm, we have demonstrated that the response to several stressors, such as injection of E. coli lipopolysaccharide (LPS) and polymicrobial sepsis induced by cecal ligation and puncture (CLP), is modified by the genetic background. The inflammatory response in mice has also been shown to be affected by sex, age, and other, nongenetic components such as diet. We have exploited the differences in response among various inbred mouse strains to map loci contributing to the inflammatory response. Fine mapping strategies allow the refinement of sets of candidate genes, which can be identified by positional cloning. Detection of genetic variation affecting the inflammatory response in murine models provides a basis for determining whether polymorphisms in orthologous human genes correlate with particular clinical outcomes from injury. Thus, discovery of these genes could impact patient care by acting as markers of a specific predisposition in humans.

Protection from lethal endotoxic shock after testosterone depletion is linked to chromosome X.

Men are considered more susceptible to sepsis after severe injury than are women, which has been attributed to a suppressing effect of male sex steroids on the inflammatory response. Moreover, the effect of sex steroids on the inflammatory process depends on the genetic background. The present study examined the genetic contribution to survival after endotoxic shock in mice depleted of testosterone by surgical castration. Six-week-old male mice, from strains A/J, AKR/J, C57BL/6J (B6), BALBc/J, DBA/2J, and C3H/HeN, were castrated (CX) or nonoperated (NoOp). Two weeks after surgery, mice were injected intraperitoneally with Escherichia coli lipopolysaccharide (15 mg/kg) and the frequency of mortality was monitored. CX A/J mice showed a significantly higher survival rate than NoOp mice, but this protective effect was not observed in the other strains. Administration of 5-alpha-dihydrotestosterone to CX A/J mice reverted the protection by CX. The protective effect of CX was also observed in crosses of female A/J and male B6 (AXB), but not female B6 and male A/J (BXA), suggesting that protection is linked to the A/J X chromosome. This possibility was corroborated by using consomic mice containing A/J chromosome X and the remaining chromosomes from B6. These results suggest that testosterone is a negative factor in the recovery from endotoxic shock, depending on the genetic background.

Combined laparoscopic-endoscopic placement of primary gastrojejunal feeding tubes in children: a preliminary report.

BACKGROUND: Placement of a primary gastrojejunal tube (GJT) can be technically challenging and often requires an open procedure to negotiate the tube past the duodenal sweep into the jejunum. The alternative approach is to first place a gastrostomy tube (GT), which is then changed to a GJT under endoscopic or fluoroscopic guidance after waiting 6-8 weeks to allow the stoma to mature. We report a case series of primary GJT placement using a combined laparoscopic-endoscopic approach. SUBJECTS AND METHODS: We retrospectively reviewed patients who underwent a combined laparoscopic-endoscopic primary GJT placement. Patients' demographics and relevant clinical information were analyzed. RESULTS: Six patients (4 male, 2 female) were identified. The median age at the time of operation was 30.2 months (range, 28 days-10 years). Five GJTs were successfully placed laparoscopically/endoscopically, and one procedure was converted to open. The mean operative time was 84 minutes (range, 63-102 minutes). Postoperative abdominal radiography confirmed post-pyloric tube position in all patients. Feedings were initiated on the first postoperative day. One intraoperative complication required conversion to an open procedure. No patients developed postoperative complications. CONCLUSIONS: Laparoscopic-endoscopic primary GJT placement is technically feasible and an excellent alternative in patients who require transpyloric feeding access.

Laparoscopic versus open treatment of congenital duodenal obstruction: multicenter short-term outcomes analysis.

BACKGROUND: Laparoscopic repair of congenital duodenal obstruction has become popularized over the past decade. Comparative data on outcomes, however, are sparse. We hypothesized that laparoscopic repair of congenital duodenal obstruction could be performed with similar outcomes to traditional open repair. PATIENTS AND METHODS: Medical records for all cases of congenital duodenal obstruction from 2005 to 2011 at three academic teaching hospitals were retrospectively reviewed. Patients were excluded from the analysis if they had confounding surgical diseases, did not have duodenoduodenostomy during the first hospital admission, had the repair performed before transfer from a referring hospital, or weighed less than 1.7 kg at the time of surgery. Analysis was performed as intention to treat, with laparoscopic converted to open cases included in the laparoscopic group. RESULTS: Sixty-four cases were included in the analysis (44 open, 20 laparoscopic). Baseline characteristics were similar between the two groups with the exception that the open group, on average, underwent repair later than the laparoscopic group (6 days versus 4 days, respectively). Seven laparoscopic cases were converted to an open procedure (35%), most commonly for difficulty in exposing the decompressed distal duodenum. Laparoscopic repair did take significantly longer than open repair (145 minutes versus 96 minutes, respectively), but clinical outcomes were similar. Complications were rare and were similar between methods of repair. Two patients in the laparoscopic group required subsequent open revision. CONCLUSIONS: Laparoscopic duodenoduodenostomy for congenital duodenal obstruction is a technically challenging procedure with a steep learning curve. Despite a relatively high conversion rate, clinical outcomes remained similar to the traditional open repair in selected patients.

Right-sided congenital diaphragmatic hernia, hepatic pulmonary fusion, duodenal atresia, and imperforate anus in an infant.

We present a case of a neonate with VACTERL-like association, with the VACTERL association defined as the non-random association of vertebral, anal, cardiac, esophageal, renal/kidney, and limb defects, as manifested by a hemivertebra, imperforate anus, and digit anomalies, in rare association with duodenal atresia and right-sided diaphragmatic hernia. This constellation is previously undescribed and may offer insight into the pathogenesis of VACTERL and associated birth defects.

Single-incision laparoscopic approach to management of splenic pathology in children: an early experience.

PURPOSE: Certain splenic conditions in children require surgical interventions, the majority of which are approached via standard laparoscopy with multiple incisions. The single-incision laparoscopic (SIL) technique is gaining popularity. The aim of this study is to review our institutional experience using the SIL technique to surgically manage different splenic pathology in the pediatric population. METHODS: A retrospective review was performed of the patients who underwent SIL splenic procedures at Miller Children's Hospital (Long Beach, CA) from January 2009 to December 2010. RESULTS: Seven patients underwent a SIL technique for different splenic diseases. Five patients underwent splenectomy, 1 patient underwent a splenic cystectomy and omental patching, and 1 patient underwent reduction of splenic torsion and splenopexy. There were no conversions to open. Six procedures were successfully performed without the need for an additional trocar. However, 1 patient required an additional grasper through a separate stab incision. There were no intraoperative complications. One patient had a superficial wound infection at 2-week postoperative follow-up, which resolved with local wound care. CONCLUSIONS: Our preliminary experience shows the SIL technique for the management of splenic pathology in children is safe and feasible.

An exaggerated inflammatory response after CLP correlates with a negative outcome.

BACKGROUND: Sepsis is the leading cause of morbidity and mortality in the surgical intensive care unit. We postulate that the variable clinical profile of septic patients is the product of multiple factors, including initiating insult, environment, and genetic make-up. This hypothesis was tested by changing the severity of the insult and the genetic background in an experimental murine model of sepsis. MATERIALS AND METHODS: Eight-week-old, male A/J and C57BL/6J (B6) mice underwent cecal ligation and puncture (CLP). The cecum was ligated just below the ileocecal valve (>1-cm ligation) or 1 cm from the end of the cecum (1-cm ligation) and single punctured using a 16- or 25-gauge needle (CLP16 or CLP25) or double punctured with a 25-gauge needle (CLP25 x 2). Cytokines were measured in plasma samples by ELISA at different time points after CLP. RESULTS: Elevated TNF-alpha and IL-6 plasma levels were observed in A/J as compared to B6 mice at 10 and 20 h after CLP16 (1-cm ligation). In contrast, IL-10 levels were decreased in A/J versus B6 mice at 6 h but increased at 10 h. After CLP25 and CLP25 x 2 (1-cm ligation), TNF-alpha was significantly increased at 10 h, but there was no difference in IL-10 and IL-6. CLP with >1-cm ligation resulted in increased cytokine expression after CLP25, CLP25 x 2, and CLP16 versus 1-cm ligation. Mortality after CLP16 was significantly higher in B6 mice with >1-cm versus 1-cm ligation. A/J mortality did not differ between the two procedures. CONCLUSION: Mortality rate and cytokine profiles after CLP vary depending on the insult severity and the genetic make-up.

IL-10 plasma levels are elevated after LPS injection in splenectomized A/J mice.

BACKGROUND: Splenectomy is clinically indicated in certain cases of hypersplenism and splenic trauma. However, it is associated with serious complications, in particular, reduced clearance of encapsulated organisms and a high incidence of sepsis, which has been coined overwhelming post-splenectomy sepsis (OPSS). In addition to the role of the spleen in the clearance of microorganisms, this organ may be involved in regulation of the inflammatory response. We investigated the effect of splenectomy on the inflammatory process induced by LPS in a murine model that resembles, in part, the pathophysiological aspects of sepsis. MATERIALS AND METHODS: Male mice (8-weeks-old) from different inbred strains were randomized into three groups: splenectomized (SPX), sham operated (SHAM), and non-operated controls (NoOp). After 9 days of recovery, mice were injected with LPS (15 mg/kg) and cytokine plasma levels were measured by ELISA at 1.5 or 6 h after injection. Peritoneal macrophages (PMphi) were isolated from the three groups, and cytokine production was evaluated after incubation with LPS in culture conditions. RESULTS: IL-10 plasma levels were elevated in SPX A/J mice (6.7 +/- 0.4 mug/ml) after injection of LPS (15 mg/kg) compared to NoOp A/J mice (4.2 +/- 0.2 mug/ml, P < 0.05). Similar elevation in IL-10 plasma levels was detected in SPX DBA/2J mice as compared to NoOp DBA/2J mice, but not in C57BL/6J and BALB/cJ mice. In contrast, SPX AKR mice displayed lower IL-10 levels than NoOp mice. PMphis from SPX A/J mice produced elevated levels of IL-10 compared to PMphis from SHAM or NoOp A/J mice, mimicking the in vivo observations. CONCLUSION: Our data suggest that the spleen plays an important role in modulating the inflammatory process induced by LPS, extending beyond passive clearance of encapsulated organisms. In addition, the contribution of the spleen to the inflammatory process may be influenced by the genetic background.