Ashish Desai

Is early delivery beneficial in gastroschisis

PURPOSE Gastroschisis neonates have delayed time to full enteral feeds (ENT), possibly due to bowel exposure to amniotic fluid. We investigated whether delivery at <37weeks improves neonatal outcomes of gastroschisis and impact of intra/extra-abdominal bowel dilatation (IABD/EABD). METHODS A retrospective review of gastroschisis (1992-2012) linked fetal/neonatal data at 2 tertiary referral centers was performed. Primary outcomes were ENT and length of hospital stay (LOS). Data (median [range]) were analyzed using parametric/non-parametric tests, positive/negative predictive values, and regression analysis. RESULTS Two hundred forty-six patients were included. Thirty-two were complex (atresia/necrosis/perforation/stenosis). ENT (p<0.0001) and LOS (p<0.0001) were reduced with increasing gestational age. IABD persisted to last scan in 92 patients, 68 (74%) simple (intact/uncompromised bowel), 24 (26%) complex. IABD or EABD diameter in complex patients was not significantly greater than simple gastroschisis. Combined IABD/EABD was present in 22 patients (14 simple, 8 complex). When present at <30weeks, the positive predictive value for complex gastroschisis was 75%. Two patients with necrosis and one atresia had IABD and collapsed extra-abdominal bowel from <30weeks. CONCLUSION Early delivery is associated with prolonged ENT/LOS, suggesting elective delivery at <37weeks is not beneficial. Combined IABD/EABD or IABD/collapsed extra-abdominal bowel is suggestive of complex gastroschisis.

Spontaneous perforation of the bile duct in infancy and childhood: a systematic review.

CASE 1 A 3-month-old boy presented with a history of jaundice, abdominal distension, vomiting, pale stools, and failure to thrive. On examination, the child was jaundiced but not unwell. The abdomen was distended with the presence of massive ascites. Bilateral hydroceles were evident. Serum liver enzymes were within normal limits. Plain abdominal film showed a ground glass appearance. Abdominal ultrasound scan (USS) showed normal liver and gallbladder with no dilatation of the intrahepatic bile ducts. No mass was detected. Radionuclide scanning demonstrated prompt visualisation of the liver and gallbladder, followed by visualisation of the CBD that looked slightly dilated. The tracer was found to be leaking into the peritoneal cavity, and there was no tracer in the intestines even at 24 hours (Fig. 1). Ascitic aspiration revealed yellow-coloured fluid. With the diagnosis of spontaneous biliary perforation in mind, a laparotomy was performed. There was a thinwalled pseudocyst at the porta hepatis. Intraoperative cholangiogram through the gallbladder showed extravasation of contrast from the CBD. A small perforation was found on the anterior wall of the CBD at the junction with the cystic duct. There was no distal obstruction. A cholecystectomy was performed and a size 8F T tube was placed into the perforation and the perforation closed around this. An external drain was left in the area of the pseudocyst. The T tube was removed once it had stopped draining and the external drained removed 2 days later. This patient was alive and well 1 year postoperatively.

Current literature and imaging techniques of aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL)

Aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) are a recognized complication of metal-on-metal bearing hip prostheses. There is an impending concern regarding the future investigation and management of patients who have received such implants. The current literature is discussed, and the current guidelines for management of these patients in the UK are reviewed. The various imaging techniques available, such as computed tomography, metal artefact reduction magnetic resonance imaging, and ultrasound are discussed and evaluated with respect to the assessment of patients with suspected ALVAL. The histopathological findings are discussed with images of the tissue changes provided. Images of the radiological findings are also provided for all general radiological methods. ALVAL and its radiological presentation is an important issue that unfortunately may become a significant clinical problem.

The risks and benefits of cisapride in premature neonates, infants, and children

The Medicines Control Agency and the Committee on Safety of Medicines (CSM) recently stated that cisapride is contraindicated in infants born before 36 weeks’ gestation for three months after birth, and that there is insufficient data to support the use of cisapride in children up to 12 years of age.1 These statements need qualification. Many believe cisapride to be a safe and useful agent in a variety of intestinal motility disorders especially in premature infants. Furthermore, data seem to support the use of cisapride throughout childhood. The only support the CSM referenced for their first statement was a study showing clinically asymptomatic electrocardiographic increases in the QTc interval to > 450 in seven of 49 neonates, six of whom were born ⩽ 33 weeks’ gestation.2 This gives reason for caution but not contraindication. Concern relates to QTc > 450, which may predispose to arrhythmias and are a risk factor for sudden infant death (SID).3Increases in QTc and arrhythmias …

Preformed Silos versus Traditional Abdominal Wall Closure in Gastroschisis: 163 Infants at a Single Institution

INTRODUCTION The surgical management of gastroschisis (GS) is controversial. The most commonly used strategy for abdominal wall closure is surgery on day 1 of life with the aim of primary closure (PC) or construction of a surgical silo (SS) and secondary closure thereafter. The other widely used technique is application of a preformed silo (PFS) and reduction of contents over a few days before final closure. There is still a paucity of comparative outcome data. METHODS A retrospective case note review of all infants initially treated at a single institution between October 1993 and October 2012. PFS was adopted as the technique of choice in April 2005. Infants with closed or closing GS were excluded. Data are presented as median (range). p < 0.05 were significant. RESULTS There were 163 infants (156 complete data sets). PFSs were applied in 67 infants and PC/SS were applied in 89 infants of whom 19 infants required a SS. There was no statistical difference between gestational age (p = 0.8), birth weight (p = 0.7), time to first (p = 0.07) and full enteral feeding (p = 0.08), length of hospital stay (p = 0.17), or necrotizing enterocolitis (p = 0.4) and mortality (p = 0.4). Infants treated with PC + SS were closed on day 0 (range, 0-11 days) versus day 6 (range, 2-22 days) of life (p < 0.001). PC + SS were ventilated for day 5 (range, 1-22 days) versus day 3.5 (range, 0-20 days) days (p = 0.01). CONCLUSION Infants treated with PFS required less ventilation than those treated by PC + SS. There was no difference in time to full feeds, length of hospital stay mortality or morbidity.

Bariatric Surgery: A Potential Treatment for Type 2 Diabetes in Youth

Type 2 diabetes, once referred to as “adult-onset” diabetes, has now emerged as a formidable threat to the health of obese adolescents. Although there is growing evidence regarding the epidemiology of type 2 diabetes in youth and its multisystem health consequences, treatment options have lagged and progression of disease occurs even with aggressive medical therapy. Increasing interest in the application of bariatric surgery for adolescents with type 2 diabetes has evolved in part because of the evidence demonstrating improvement or remission in many adults with diabetes after surgery. Here, we review the burden of type 2 diabetes in youth including its associated complications, discuss the outcomes and complications of bariatric surgery in adolescents with diabetes, and conclude with recommendations for future research and options for refinement of the use of bariatric surgery in this patient population.

Assessment of Diet and Physical Activity in Paediatric Non-Alcoholic Fatty Liver Disease Patients: A United Kingdom Case Control Study

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children, with prevalence rising alongside childhood obesity rates. This study aimed to characterise the habitual diet and activity behaviours of children with NAFLD compared to obese children without liver disease in the United Kingdom (UK). Twenty-four biopsy-proven paediatric NAFLD cases and eight obese controls without biochemical or radiological evidence of NAFLD completed a 24-h dietary recall, a Physical Activity Questionnaire (PAQ), a Dutch Eating Behavior Questionnaire (DEBQ) and a 7-day food and activity diary (FAD), in conjunction with wearing a pedometer. Groups were well matched for age and gender. Obese children had higher BMI z-scores (p = 0.006) and BMI centiles (p = 0.002) than participants with NAFLD. After adjusting for multiple hypotheses testing and controlling for differences in BMI, no differences in macro- or micronutrient intake were observed as assessed using either 24-h recall or 7-day FAD (p > 0.001). Under-reporting was prevalent (NAFLD 75%, Obese Control 87%: p = 0.15). Restrained eating behaviours were significantly higher in the NAFLD group (p = 0.005), who also recorded more steps per day than the obese controls (p = 0.01). In conclusion, this is the first study to assess dietary and activity patterns in a UK paediatric NAFLD population. Only a minority of cases and controls were meeting current dietary and physical activity recommendations. Our findings do not support development of specific dietary/ physical activity guidelines for children with NAFLD; promoting adherence with current general paediatric recommendations for health should remain the focus of clinical management.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

What Is the Evidence for Paediatric/Adolescent Bariatric Surgery?

Purpose of ReviewIn spite of the increasing prevalence of severe and complex obesity in children, surgery as a potential management option is still not widely accepted. The purpose of this review is to examine the evidence for surgical options in the severely obese paediatric population. Increasing evidence supports early rather than later use of bariatric surgery in the treatment of extreme obesity.Recent FindingsPrior to 2007, the feasibility and safety of surgery have been reported by predominantly small, sporadic single-centre retrospective case series. Increasing long-term data is now emerging due to the formation of multi-centre prospective national consortiums with two large, prospective long-term outcome studies published within the last year aiding our understanding of the efficacy and safety of bariatric surgery within the adolescent population.SummaryIt is increasingly clear that adolescent bariatric surgery outcomes are comparable to adults, with similar sustainable weight loss, resolution of co-morbidities and complication rates. However, these studies are solely from dedicated specialist adolescent centres and results may not be reproducible if not performed in regulated environments with specialist multi-disciplinary teams.

Weight loss surgery improves quality of life in pediatric patients with osteogenesis imperfecta

BACKGROUND Osteogenesis imperfecta (OI) is an inherited disorder, which causes brittle bones resulting in recurrent fractures. The associated poor mobility of children with OI increases susceptibility to obesity, and obesity further dramatically limits mobility and increases fracture risk. OBJECTIVES The aim of this report is to describe outcomes of weight loss surgery (WLS) in 2 adolescents with severe obesity and OI. SETTING Two University Hospitals (in the United Kingdom and in the United States). METHODS Two cases of OI treated with WLS were identified. Pre- and postoperative anthropometric and biochemical data and clinical course were reviewed. RESULTS In these 2 cases, preoperative Body Mass Index (BMI) values were 38 and 46 kg/m2. Following laparoscopic sleeve gastrectomy (LSG), BMI decreased by 55% and 60% by 26 and 24 months, respectively. There were no surgical complications, and both patients experienced improvement in their mobility and ability to perform activities of daily living. CONCLUSION WLS effectively treated severe obesity in 2 OI patients and substantially improved mobility and quality of life, theoretically reducing fracture risk.