Bowel obstruction following pediatric abdominal cancer surgery.

INTRODUCTION: Pediatric bowel obstruction after intra-abdominal cancer surgery is relatively frequent. Few publications have specifically addressed this significant complication. The purpose of this study was to assess the frequency, etiology and treatment options of bowel obstructions following abdominal cancer surgery in children using our institutional database. MATERIALS AND METHODS: We retrospectively analyzed a single tertiary pediatric hospital database over a 10-year period. The clinical characteristics of patients with and without bowel obstruction were compared using bivariate analyses. The details of the conservative and operative management of bowel obstructions were evaluated. RESULTS: Out of 130 eligible patients, 18 (13.8%) developed bowel obstruction in a mean follow-up of 5.7 years. Patients who developed bowel obstruction were more likely to have received preoperative radiation therapy (16.7 vs 2.7%, p = 0.036) and had longer operative time (398 vs 268 min, p = 0.022). Non-operative management was successful in 39% of patients (7/18). When patients needed surgical intervention, minimally invasive approach was attempted and successfully performed in 36% of cases (4/11), none of which required conversion to laparotomy nor presented with recurrent bowel obstruction. CONCLUSION: Bowel obstruction is a frequent complication after abdominal cancer surgery in children. Conservative management is frequently successful. For patients requiring surgical treatment, laparoscopy remains a valuable option and should be considered in selected cases.

Trauma experts versus pediatric experts: comparison of outcomes in pediatric penetrating injuries.

BACKGROUND: While pediatric trauma centers (PTCs) can uniquely care for pediatric patients, adult trauma centers (ATCs) may be more accessible. Evidence is scarce regarding outcomes of pediatric patients with penetrating trauma treated at PTCs versus ATCs. MATERIALS AND METHODS: We performed a retrospective study using the National Trauma Data Bank to identify pediatric patients aged ≤18 y with penetrating injuries from 2007 to 2012, treated at stand-alone PTCs or ATCs. We excluded patients treated at combined PTC or ATC, transferred between hospitals, with gunshot wounds (GSW) to the head, or dead on arrival. Eligible patients numbered 26,276 (PTC, n = 3737; ATC, n = 22,539). The primary outcome was in-hospital mortality. The secondary outcome was discharge location as a potential surrogate for functional outcome. Univariate and multivariate analyses assessed trauma center type as an independent risk factor for outcomes. RESULTS: Patients treated at ATCs were more likely to have Injury Severity Score >15, Glasgow Coma Scale <9, GSW, cardiovascular injuries, and emergent operations (P < 0.001). Adjusted odds ratios (ORs) for mortality favored PTCs but without statistical significance (OR, 0.592; P = 0.054). In subgroup analyses, children with aged ≤12 y, those with GSW injury mechanism, and those who underwent emergent operations at PTCs were more frequently discharged home versus elsewhere (OR, 0.327, 0.483, and 0.394; P values <0.001, <0.001, and 0.004, respectively). CONCLUSIONS: Children with penetrating injuries demonstrated equivalent survival outcomes whether they were treated at PTCs or ATCs. Younger pediatric patients may have superior functional outcomes when treated at PTCs.

The role of simultaneous abdominal surgery and wound classification in ventriculoperitoneal shunt complication.

PURPOSE: To evaluate whether simultaneous abdominal surgery or wound contamination at the time of ventriculoperitoneal (VP) shunt placement are associated with increased shunt complications. METHODS: Pediatric patients who underwent VP shunt placement were identified using the National Surgical Quality Improvement Program Pediatric database. VP shunt complication rates were compared between patients who underwent simultaneous abdominal surgeries at the time of VP shunt placement vs those who did not and between those with clean/clean-contaminated and contaminated/dirty wound classifications. Adjusted analysis was performed using 1:5 case-control matching. RESULTS: Among 2715 patients who underwent VP shunt placement, 21 had simultaneous abdominal procedures and were matched with 105 control patients. No significant difference was found in overall (34.3 vs 14.3%, p = 0.07), infectious (8.6 vs 4.8%, p = 1.000), or non-infectious (25.7 vs 9.5%, p = 0.156) shunt complications in the simultaneous vs non-simultaneous group, respectively. In a separate analysis of wound classification, 12 patients with contaminated/dirty wounds were matched with 60 patients with clean/clean-contaminated wounds. The rates of shunt infections for clean/clean-contaminated and contaminated/dirty cases were 10.0 and 16.7%, respectively (p = 0.613). CONCLUSION: In our matched case-control study, neither simultaneous abdominal surgery nor wound contamination at the time of VP shunt placement demonstrated significant increased risk of 30-day post-operative complication.

Recurrent Ileocolic Intussusception With the Appendix as the Pathologic Lead Point in Children: A Report of Two Cases and Review of Literature.

Ileocolic intussusception is a consideration in young pediatric patients with acute abdominal pain. Meckel's diverticulum is the most common pathologic lead point for intussusception in children and the appendix acting as the lead point is rare. In addition, management guidelines for recurrent ileocolic intussusception (RICI) are lacking. We present two cases of RICI in which the pathological lead point was the appendix. The first patient, a two-year-old with no medical history, had intermittent abdominal pain and non-bloody vomiting for a month. Ultrasound revealed ileocolic intussusception, successfully managed with pneumatic reduction. However, symptoms recurred and a repeat ultrasound showed partial intussusception of the appendix into the cecum. Laparoscopic reduction and appendectomy were then performed. Symptomatic intussusception recurred, and a second laparoscopic reduction with stump appendectomy resolved all symptoms. The second patient, a three-year-old with no medical history, had colicky abdominal pain for 24 hours. Ultrasound revealed ileocolic intussusception that was pneumatically reduced. As pain recurred, laparoscopic reduction and appendectomy were performed, revealing ileocolic intussusception with a dilated appendix as the pathologic lead point. Recurrent ileocolic intussusception (RICI) with the appendix as the lead point is common, but RICI with the appendix as the lead point is rare. These cases demonstrate the role of the appendix as a pathologic lead point, and a review of the literature supports the need for surgical reduction. While enema reduction is the first line for recurrent intussusception, surgical reduction is preferred when a pathological lead point is suspected.

Development of rapid, sensitive and non-radioactive tissue-blot diagnostic method for the detection of citrus greening.

Citrus huanglongbing (HLB or citrus greening) is one of the most devastating diseases of citrus worldwide. The disease is caused by Gram-negative, phloem-limited α-proteobacterium, 'Candidatus Liberibacter asiaticus', vectored by the psyllid, Diaphorina citri Kuwayama. Citrus plants infected by the HLB bacterium may not show visible symptoms sometimes for years following infection and non-uniform distribution within the tree makes the detection of the pathogen very difficult. Efficient management of HLB disease requires rapid and sensitive detection early in the infection followed by eradication of the source of pathogen and the vector. The polymerase chain reaction (PCR) based method is most commonly employed for screening the infected/suspected HLB plants and psyllids. This is time consuming, cumbersome and not practical for screening large number of samples in the field. To overcome this, we developed a simple, sensitive, non-radioactive, tissue-blot diagnostic method for early detection and screening of HLB disease. Digoxigenin labeled molecular probes specific to 'Ca. L. asiaticus' nucleotide sequences have been developed and used for the detection of the pathogen of the HLB disease. The copy number of the target genes was also assessed using real-time PCR experiments and the optimized real-time PCR protocol allowed positive 'Ca. L. asiaticus' detection in citrus samples infected with 'Ca. L. asiaticus' bacterium.

Reductive evolution suggested from the complete genome sequence of a plant-pathogenic phytoplasma.

The minimal gene set essential for life has long been sought. We report the 860-kb genome of the obligate intracellular plant pathogen phytoplasma (Candidatus Phytoplasma asteris, OY strain). The phytoplasma genome encodes even fewer metabolic functions than do mycoplasma genomes. It lacks the pentose phosphate cycle and, more unexpectedly, ATP-synthase subunits, which are thought to be essential for life. This may be the result of reductive evolution as a consequence of life as an intracellular parasite in a nutrient-rich environment.

An Extreme Case of Lethal Abdominal Compartment Syndrome in Pediatric Patient With Synovial Sarcoma.

There is a relative paucity of literature on abdominal compartment syndrome (ACS) in children compared to adults and even less describing ACS in pediatric oncologic patients. We present this case of ACS in a 14-year-old patient to highlight the acuity of lethal consequences despite swift adequate management. Our patient is a 14-year-old male with a history of non-verbal autism and large synovial sarcoma of the left chest wall. He was admitted for scheduled inpatient chemotherapy and radiation. On day 3 of admission, the patient's clinical condition rapidly deteriorated, and a surgical abdomen was found on the exam. In the operating room (OR), massive gaseous distention of the stomach, small intestines, and colon were noted. A loop of small bowel was under such high pressure that the force of evisceration sheared the bowel from the associated mesentery. Due to the severity of the dilated bowel loops, we could not return the eviscerated bowel back inside the abdomen, which led us to leave the Abthera wound vac as sole coverage. The patient was transferred to the PICU, and medical treatment was aimed toward palliative care. The patient passed away three hours later. This case illustrates the acute and lethal nature of ACS in a less studied population, the pediatric oncologic patient. Prompt detection and treatment of ACS are essential for the management of critically ill pediatric patients, especially in those with space occupying tumors within the abdominal cavity. However, extreme presentations of ACS can have lethal consequences despite swift surgical intervention and adequate management.

The Extremes of Constipation: A Case of Stercoral Perforation From Fecal Impaction in a Teenager.

Stercoral perforation is a rare sequela of poorly controlled constipation that is more commonly seen in older, bedridden patients than in pediatric patients. We present the case of a 13-year-old patient requiring a divided sigmoid colostomy following rectal perforation, one of the few examples in the pediatric literature of stercoral perforation from chronic constipation. The current report highlights the importance of appropriate treatment of functional constipation at onset and the life-threatening complications that can occur without appropriate follow-up.

Tu-be or not tu-be? Is routine endotracheal intubation necessary for successful bedside reduction and primary closure of gastroschisis?

BACKGROUND: Wide practice variation exists in the management of gastroschisis. Routine endotracheal intubation for bedside closure may lead to longer duration of mechanical ventilation. METHODS: The Canadian Association of Pediatric Surgery Network gastroschisis dataset was queried for all patients undergoing attempted bedside reduction and closure. Patients with evidence of intestinal necrosis or perforation were excluded. A propensity score analysis was used to compare the rate of successful primary repair and post-operative outcomes between intubated and non-intubated patients. RESULTS: In propensity score matched analysis, the successful primary repair rate did not reach statistical significance between patients who were intubated for attempted bedside closure and those who were not intubated (Odds Ratio: 2.18, 95% Confidence Interval: 0.79, 6.03). Intubated patients experienced 3.02 more ventilator days than patients who were not intubated at the time of initial attempted closure. Other post-operative parameters were similar between both groups. CONCLUSIONS: It is reasonable to attempt primary bedside gastroschisis closure without intubation in otherwise healthy infants.

Congenital Giant Megaureter in a 16-Year-Old Female Presenting With Abdominal Pain: A Case Report and Review of Literature.

We describe a case of congenital giant megaureter in a 16-year-old female. She presented with a 5-day history of abdominal distention, right flank pain and tenderness. Right pyelonephritis was suspected. Computerized tomography showed a large cystic abdominal mass with no appreciably functioning left kidney causing secondary compression of the contralateral right ureter. A left upper nephroureterectomy was performed, draining over 3.5 L of fluid. Our experience suggests that congenital giant megaureter should be considered in the differential for pediatric patients presenting with a cystic abdominal mass.

Single-Incision Laparoscopic Appendectomy Using Standard 5 mm Trocars: Single Pediatric Center Experience.

Purpose: Single-incision laparoscopic appendectomy (SILA) for the treatment of appendicitis has been documented. Typically, SILA requires the use of specialized ports, instruments, and materials. The SILA technique at our institution utilizes the same instrumentation as the conventional laparoscopic approach (CLA), thus obviating the need for these specialized products. This study aims to further demonstrate the noninferiority of our SILA technique for the treatment of uncomplicated appendicitis. Materials and Methods: This is a single-institution retrospective review of patients who underwent SILA from 2011 to 2020 to treat uncomplicated appendicitis. Outcomes including demographics, operative time, length of stay (LOS), and common postsurgical complications were evaluated. These SILA cases were matched with up to 3 CLA controls based on age, gender, and weight utilizing the Greedy match method. Patients with an operative diagnosis of perforated appendicitis were excluded. Results: A total of 137 patients underwent SILA at a single institution. A total of 128 patients were in the final cohort after excluding perforated appendicitis. Mean age was 11.9 years. Case-control matching was conducted with 349 controls included. Between cases and controls, SILA had shorter operative time (27.2 minutes versus 43.7 minutes, P < .001) with no difference in mean LOS (42.4 hours versus 42.4 hours, P = .88). There was no difference in complication rate (5.4% versus 8.5%, P = .06). There was no difference in readmission rate (0.8% versus 3.4%, P = .108). Conclusion: These data suggest that for appropriately selected patients, our SILA technique is noninferior to CLA with shortened operative time.

Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes.

PURPOSE: Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes. METHODS: We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008-2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success. RESULTS: Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01). CONCLUSIONS: Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications. Level of Evidence III Type of Study Retrospective comparative study.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury.

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

Presenting a Case of an Extralobar and Extrapleural Pulmonary Sequestration in a Four-Month-Old Infant.

Pulmonary sequestration is a congenital disease formed by embryogenic separation of the lung parenchyma, halting development and function. It has an aberrant blood supply and can provide a nidus for infection and respiratory compromise. It can be diagnosed prenatally with surgical resection after delivery reserved as the best mode of treatment. In literature, six to twelve months is the most optimal time for elective surgical repair giving time for some maturation to withstand single lung ventilation and operation before the risk of infection heightens after 12 months. We present a case of an infant that had an elective repair at four months of age with no postoperative sequelae highlighting that surgeons can perform elective repair sooner than six months of age and that surgical decision-making should be on a case-by-case basis.

Surgical Reconstruction Options for a Case of Near Total Intestinal Aganglionosis.

Hirschsprung's disease is a congenital anomaly affecting neural crest cell migration and proliferation in the myenteric plexi resulting in dysmotility, which can present as bilious emesis, delayed meconium passage, and bowel obstruction in neonates, or chronic constipation in older children. Depending on the extent of aganglionosis, this disease can involve the whole gut. Treatment involves a temporary ostomy and interval definitive surgical reconstruction. In patients with near or total intestinal aganglionosis, however, there is no consensus on the most effective surgical reconstruction as consideration of the length and function of the normal remnant bowel create concerns for complications with short bowel syndrome post-operatively. We present a case of near-total intestinal aganglionosis highlighting the various options for definitive surgical reconstruction.

Traumatic Left Anterior Descending Artery Dissection in a Case of Pediatric Blunt Chest Trauma.

Despite the reserve for recovery in pediatric trauma, blunt force chest trauma can cause insidious injuries that are easy to miss. Coronary artery dissection is a rare injury associated with blunt force chest trauma in the pediatric population and can present with vague or atypical symptoms. Pediatric patients can be unreliable in reporting symptoms, and providers can mistake coronary artery injuries for myocardial contusion, especially with improving laboratory tests and equivocal imaging. We report a case showing the importance of a high index of suspicion when presented with this trauma pattern in a pediatric patient.

Evaluation of genetic diversity among 'Candidatus Liberibacter asiaticus' isolates collected in Southeast Asia.

The aim of this study was to investigate the genetic diversity and relationships among 'Candidatus Liberibacter asiaticus' isolates from different hosts and distinct geographical areas in Southeast Asia. Genetic diversity among 'Ca. Liberibacter asiaticus' was estimated by sequencing four well-characterized DNA fragments: the 16S ribosomal DNA (rDNA) and 16S/23S intergenic spacer regions; the outer membrane protein (omp) gene region; the trmU-tufB-secE-nusG-rplKAJL-rpoB region (gene cluster region); and the bacteriophage-type DNA polymerase region. The sequences of the 16S rDNA and 16S/23S intergenic spacer regions were identical among all 'Ca. Liberibacter asiaticus' isolates. In contrast, nucleotide substitutions were observed in both the omp gene and the gene cluster regions. However, extended bacteriophage-type DNA polymerase sequences acquired by thermal asymmetric interlaced polymerase chain reaction provided the most sequence diversity among isolates. Phylogenetic analysis of the bacteriophage-type DNA polymerase sequences revealed three clusters in the Southeast Asian 'Ca. Liberibacter asiaticus' population. All Indonesian 'Ca. Liberibacter asiaticus' isolates clustered in one group. The other clusters were not correlated with geographic distribution. The differences in genetic sequences did not reflect differences in the original citrus host (mandarin or pummelo). These results suggest that the bacteriophage-type DNA polymerase region would be useful for molecular differentiation between different Southeast Asian 'Ca. Liberibacter asiaticus' isolates.

Apple aminopropyl transferase, MdACL5 interacts with putative elongation factor 1-alpha and S-adenosylmethionine synthase [corrected].

Several lines of evidence suggest different allocations of the physiological roles of aminopropyl transferase genes, SPMS and ACL5 in plants. To get deeper insights into the physiological role of apple ACL5 (MdACL5), we performed yeast two-hybrid (Y2H) assay to identify proteins which interact with MdACL5. After intense screening processes, including the swapping of the bait and prey vectors and in vitro coimmunoprecipitation, we identified three MdACL5-interacting proteins: putative translation elongation factor 1A (eEF-1A), putative S-adenosyl-l-methionine synthetase (SAMS) and an unknown protein. Results from Y2H and RNA gel blot analysis suggested the involvement of MdACL5 and eEF-1A or SAMS complexes in the plant growth and development of the organized tissues and/or organs.

The rate of PD catheter complication does not increase with simultaneous abdominal surgery.

INTRODUCTION: Children with kidney failure requiring PD catheter placement often require additional intraabdominal surgery. However, the risk of complication related to simultaneous abdominal surgery at time of catheter placement is unknown. METHODS: Patients (0-18years) who underwent PD catheter placement (2012-2015) in the NSQIP-P database were reviewed. Complication rates between patients who underwent additional abdominal surgery at the time of PD catheter placement and those that did not were evaluated. One to one case control matching was performed for additional adjusted analysis. RESULTS: Of 563 patients who met inclusion criteria, 82 underwent simultaneous abdominal surgery at time of PD catheter placement. Patients in the simultaneous group had a higher rate of wound contamination but there was no difference in rates of SSI, 30-day PD catheter complication, or 30-day mortality compared with the nonsimultaneous group. There was no difference when overall simultaneous abdominal surgery or gastrointestinal surgery was evaluated. In our 1:1 adjusted analysis, there was a higher rate of PD catheter complication (11.3% vs. 2.8%, p=0.049) and SSI (31.0% vs. 4.2%, p<0.001) in the nonsimultaneous group. CONCLUSIONS: Thirty-day PD catheter complication and SSI in patients who underwent simultaneous abdominal surgery at time of catheter placement were noninferior to outcomes in the nonsimultaneous. LEVEL OF EVIDENCE: Level III, Treatment study, Retrospective comparative study.

Molecular and Serological Characterization of Cucumber mottle virus, a New Cucurbit-Infecting Tobamo-like Virus.

A new tobamo-like virus was isolated from a greenhouse-grown cucumber that showed severe mosaic distortion on leaves and fruit, in the southern part of Japan. The virus was tentatively designated Cucumber mottle virus (CuMoV) and further characterized. The size and antigenicity of the coat protein (CP) and the complete sequence of the genome were compared with those of the known cucurbit-infecting tobamoviruses: the W and SH strains of Cucumber green mottle mosaic virus (CGMMV), the C and Y strains of Kyuri green mottle mosaic virus (KGMMV), Cucumber fruit mottle mosaic virus (CFMMV), and Zucchini green mottle mosaic virus (ZGMMV). The CP of CuMoV migrated more slowly than those of CGMMV-W and -SH and KGMMV-C and -Y in sodium dodecyl sulfate polyacrylamide gel electrophoresis. In Western blot analysis, the CP of CuMoV cross-reacted weakly with antisera against CGMMV-W and did not react with antisera against KGMMV-Y. The overall nucleotide sequence of CuMoV had 62.5 to 63.5% identity with those of CGMMV-W, -SH, KGMMV-Y, CFMMV, and ZGMMV. The genome organization was characteristic of tobamoviruses, encoding a 131-kb protein, a 188-kb protein, a movement protein (MP), and CP in 5' to 3' order. In the phylogenetic analyses of the CP, CuMoV was placed in a separate lineage from CGMMV-W, -SH, KGMMV-C, -Y, CFMMV, and ZGMMV. The results indicate that CuMoV is a distinct tobamovirus species which represents a third sub-subgroup in the cucurbit-infecting tobamoviruses.