David C. van der Zee

European consensus on a competency-based virtual reality training program for basic endoscopic surgical psychomotor skills

BackgroundVirtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program.MethodsA consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the t test for equality of means.ResultsConsensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference.ConclusionsA European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.

Noninvasive measurement of fecal calprotectin and serum amyloid A combined with intestinal fatty acid–binding protein in necrotizing enterocolitis

BACKGROUNDnDiagnosis of necrotizing enterocolitis (NEC), prevalent in premature infants, remains challenging. Enterocyte damage in NEC can be assessed by intestinal fatty acid-binding protein (I-FABP), with a sensitivity of 93% and a specificity of 90%. Numerous markers of inflammation are known, such as serum amyloid A (SAA) and fecal calprotectin.nnnPURPOSEnThe aim of the present study was to evaluate which combination of noninvasive measurement of inflammatory markers and I-FABP improves the diagnostic accuracy in neonates suspected for NEC.nnnMETHODSnIn 62 neonates with clinical suspicion of NEC (29 with final diagnosis of NEC), urinary I-FABP, urinary SAA, and fecal calprotectin levels were determined quantitatively. Diagnostic accuracy was calculated for the combinations I-FABP-SAA and I-FABP-fecal calprotectin, using a multivariable logistic regression model.nnnRESULTSnThe combination of SAA and I-FABP did not increase the diagnostic accuracy of I-FABP. However, the combination of fecal calprotectin and I-FABP improved accuracy significantly. The combination of urinary I-FABP and fecal calprotectin measurement produced a sensitivity of 94%, a specificity of 79%, a positive likelihood ratio of 4.48, and a negative likelihood ratio of 0.08.nnnCONCLUSIONnThe combination of noninvasive measurement of I-FABP and fecal calprotectin seems promising for diagnosing NEC at an early time point. Prospective analysis is required to confirm this finding and to evaluate better treatment strategies based on noninvasive measurement of I-FABP and calprotectin.

Laparoscopic treatment of intestinal malrotation in neonates and infants: retrospective study

BackgroundIntestinal malrotation in neonates or infants may require urgent surgical treatment, especially when volvulus and vascular compromise of the midgut are suspected. Successful laparoscopic management of malrotation has been described in a number of case reports. It remains unclear, however, whether laparoscopy for the treatment of malrotation has a success rate equal to that of open surgery and what relative risks exist in terms of conversion and redo surgery in larger numbers of patients. This report describes a retrospective analysis of the clinical outcome for 45 children who underwent laparoscopic treatment of intestinal malrotation at the authors’ institution.MethodsThe 45 patients in this series, ages several days to 13xa0years, underwent a diagnostic laparoscopy for suspected intestinal malrotation. For 37 patients, malrotation with or without volvulus was diagnosed. All these patients underwent laparoscopic derotation and Ladd’s procedure.ResultsSuccessful laparoscopic treatment of intestinal malrotation could be performed in 75% of the cases (nxa0=xa028), and conversion to an open procedure was necessary in 25% of the cases (nxa0=xa09). The median hospital stay was 11xa0days (range, 2–60xa0days). Postoperative clinical relapse due to recurrence of malrotation, volvulus, or both occurred for 19% of the laparoscopically treated patients (nxa0=xa07). These patients underwent laparoscopic (nxa0=xa01) or open (nxa0=xa06) redo surgery.ConclusionDiagnostic laparoscopy is the procedure of choice when intestinal malrotation is suspected. If present, malrotation can be treated adequately with laparoscopic surgery in the majority of cases. Nevertheless, to prevent recurrence of malrotation or volvulus, a low threshold for conversion to an open procedure is mandated.

Barrett's esophagus in children: Does it need more attention?

BACKGROUNDnFew studies have reported on Barretts esophagus (BE) in children. Moreover, information on the age at diagnosis and the duration between reflux-symptoms and diagnosis is lacking.nnnMETHODSnA review of the literature was performed in PubMed, EMBASE and the Cochrane database.nnnRESULTSnFourteen articles were included, of which 4 cohort studies and 10 studies investigating patients already diagnosed with BE. The cohort studies showed 37 patients diagnosed with BE (0.3-4.8%), mean age 12.4 years. Time between onset of reflux-symptoms and BE was 2.8 years. All 14 studies together showed 176 patients with BE (mean age 9.5 years). Time between onset of reflux-symptoms and BE was 5.3 years. During endoscopic follow-up of 45 patients, 26 still had BE, 17 no longer had evidence of BE, and two had developed esophageal-adenocarcinoma.nnnCONCLUSIONnThis review shows that BE and esophageal-adenocarcinoma occur in children. However, criteria used to define BE by the included studies were not comparable to the current criteria and data on GERD symptoms may have been inaccurate. Therefore, we recommend performing a long-term prospective study on the relationship between (duration of) GERD and the development of BE in children in order to define screening guidelines.

Non-invasive serum amyloid A (SAA) measurement and plasma platelets for accurate prediction of surgical intervention in severe necrotizing enterocolitis (NEC).

Objective To evaluate the value of biomarkers to detect severe NEC. Summary Background Data The time point of surgery in necrotizing enterocolitis (NEC) is critical. Therefore, there is a need for markers that detect severe NEC, because clinical signs of severe NEC often develop late. This study evaluated the value of biomarkers reflecting intestinal cell damage and inflammation to detect severe NEC. Methods 29 neonates with NEC were included. Two definitions of moderate versus severe NEC were analyzed: medical NEC (nu200a=u200a12) versus surgical or fatal NEC (nu200a=u200a17); and Bell stage II NEC (nu200a=u200a13) versus stage III NEC (nu200a=u200a16). Urinary intestinal fatty acid binding protein (I-FABP), serum amyloid A (SAA), C3a and C5a, and fecal calprotectin were measured. C-reactive protein (CRP), white blood cell count (WBC) and platelet count data were measured in blood. Results In both definitions of moderate versus severe NEC, urinary SAA levels were significantly higher in severe NEC. A cut-off value of 34.4 ng/ml was found in surgical NEC versus medical NEC (sensitivity, 83%; specificity, 83%; LR+, 4.88 (95% CI, 1.37–17.0); LR−, 0.20 (95% CI, 0.07–0.60)) at diagnosis of NEC and at one day prior to surgery in neonates who were operated later on. Combination of urinary SAA and platelet count increased the accuracy, with a sensitivity, 94%; specificity, 83%; LR+, 5.53 (95% CI, 1.57–20.0); and LR−, 0.07 (95% CI, 0.01–0.48). Conclusion Urinary SAA is an accurate marker in differentiating severe NEC from moderate NEC; particularly if combined with serum platelet count.

Malignant transformation in sacrococcygeal teratoma and in presacral teratoma associated with Currarino syndrome: a comparative study

BACKGROUND/PURPOSEnThe risk of malignant transformation of sacrococcygeal teratoma (SCT) and of presacral teratoma in Currarino syndrome (CS) may differ despite the similar position and appearance.nnnMETHODSnMalignant transformation and teratoma recurrence were assessed in a national retrospective comparative analysis of 205 SCT and 16 CS patients treated in one of the six pediatric surgical centers in the Netherlands between January 1981 and December 2010.nnnRESULTSnThe malignancy free survival of patients with SCT was lower than for patients with a presacral teratoma associated with CS (80% and 58% after one and two years in SCT versus 100% after two years in CS, p=0.017) CONCLUSIONS: In SCT, malignancy and recurrence risk are high. Therefore, early and complete resection is mandatory. Our data show that the risk of malignant transformation of a presacral teratoma in CS is small.

Total biliary diversion as a treatment option for patients with progressive familial intrahepatic cholestasis and Alagille syndrome

BACKGROUNDnProgressive familial intrahepatic cholestasis (PFIC) with low gamma-glutamyl transpeptidase (GGT) and Alagille syndrome are associated with persistent cholestasis and severe pruritus. Various types of biliary diversion have been used to reduce this pruritus and prevent liver dysfunction. We report our experience concerning the efficacy and safety of total biliary diversion (TBD) as an additional treatment option.nnnMETHODSnTBD was performed in four PFIC patients and one patient with Alagille syndrome, and was accomplished by anastomosing a jejunal segment to the choledochal duct terminating as an end stoma, or by disconnecting the choledochal duct after previous cholecystojejunocutaneostomy.nnnRESULTSnTBD resulted in a marked improvement of symptoms and biochemical parameters in all PFIC patients. Despite relief of pruritus, cholestasis persisted in the Alagille patient. During 5-15years of follow-up, no clinical signs of fat malabsorption such as diarrhea or weight loss were encountered. However, to maintain adequate levels of fat-soluble vitamins, especially of vitamin K, substantial supplementation was necessary.nnnCONCLUSIONSnTotal biliary diversion can be a useful surgical treatment option for patients with low-GGT PFIC and possibly also Alagille syndrome, when partial biliary diversion is insufficient. It can be performed without inducing clinical signs of fat malabsorption although individualized supplementation of fat-soluble vitamins with careful monitoring is warranted.

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis.

Background: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. Methods: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. Results: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. Conclusions: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.

Laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant.

We describe the laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant. Initial laparoscopic primary repair with nonabsorbable interrupted sutures resulted in recurrence, but subsequent laparoscopic mesh repair led to satisfying results. A lumbar hernia is defined as the protrusion of an organ or tissue through a defect in the posterolateral abdominal wall. This type of hernia is extremely rare. In 1774, Petit reported a patient with a strangulated lumbar hernia. He also described the anatomical borders of the (inferior) lumbar triangle through which the hernia protruded.1 Although he was not the first to publish on this subject, the inferior triangle and the associated hernia are nowadays associated with Petit. Nearly a century later, in 1866, the existence of a superior lumbar triangle was reported by Grynfeltt.2 The inferior lumbar triangle (Petit) is an upright triangular space. Its boundaries are the posterior border of the external oblique muscle anteriorly, the anterior border of the latissimus dorsi muscle posteriorly and the iliac crest inferiorly. Its roof is the superficial fascia and its floor the internal oblique muscle. The superior lumbar triangle (Grynfeltt) is an inverted triangular space. Its borders consist of the posterior border of the internal oblique muscle anteriorly, the anterior border of the sacrospinalis muscle posteriorly, and the 12th rib and serratus posterior inferior muscle superiorly. The roof is formed by the latissimus dorsi muscle and the floor by the aponeurosis of the transversus abdominis muscle.3 In 2007, Moreno-Egea et al estimated that 300 cases of lumbar hernia, protruding through the inferior or superior lumbar triangles, have been reported in the medical literature.4 Approximately 80% of these hernias are considered to be acquired (i.e., incisional or postinfectious) while 20% are thought to be congenital.5 Consistent with these findings, in 2008, Akcora et al reported that a total of 60 congenital hernias have been described.6 In 20 cases, the congenital hernias were associated with the lumbocostovertebral syndrome.7–9 This syndrome includes hemivertebrae, absence of ribs, anterior myelomeningocele, and abdominal wall muscular hypoplasia. Other abnormalities associated with congenital lumbar hernia have been described as well. However, no additional anomalies were found in our patient. Isolated bilateral congenital hernia and open repair in an infant have been described before for the first and, to our knowledge, only time in 2002.10 Here, we report for the first time the laparoscopic repair of this type of bilateral hernia in a baby.

MATERNOEMBRYONIC TRANSFUSION AND CONGENITAL MALFORMATIONS

There is an increasing number of reports relating chorionic villus sampling (CVS) to transverse limb reduction defects or the oromandibular limb hypogenesis complex. In addition, a correlation has been established between the severity of the defect and the gestational age when CVS is performed. Several hypotheses have been proposed for the increased incidence of congenital malformations after CVS including vascular disruption. Recently, it has been suggested that maternoembryonic transfusion can occur after CVS and that this can lead to a local antibody‐mediated reaction, followed by local pathogenetic cell degeneration, i.e., apoptotic cell death, due to vascular disruption. This increased apoptotic cell death will ultimately result in congenital malformations. This paper describes an experimental model that can explain the pathogenesis of congenital malformations after CVS. The model designed uses a whole rat embryo culture technique and intracardiac injection of antisera, mimicking transplacental transfusion after CVS. Injection of antibodies directed against blood group antigens is capable of inducing increased apoptotic cell death. Immunological staining gives evidence of involvement of antibody‐mediated reactions in the occurrence of apoptotic cell death. The dorsal aortae in 10‐day‐old rat embryos of 10‐somite stages of development consist of a continuous endothelial cell layer. The effect of intracardiac injection of antisera on the dorsal aortae is only transient. Smaller vessels such as the pharyngeal arch arteries or arteries of the limbs still have fenestrated endothelium and are therefore more vulnerable to the pathogenetic effect of the reaction after transplacental transfusion causing vascular disruption. Development of the vascular pattern and differentiation of the vascular wall reduce the risk of severe malformations later on in pregnancy, although the risk of malformations remains throughout pregnancy. Thus, intracardiac injection of antisera simulating maternoembryonic transfusion such as after CVS can lead to an antibody‐mediated reaction with vascular disruption early in pregnancy inducing apoptotic cell death. Increased cell death may ultimately result in congenital malformations, such as transverse limb defects or the oromandibular limb hypogenesis complex.