David T. Schindel

Trophic effects of interleukin-11 in rats with experimental short bowel syndrome

Interleukin-11 (IL-11) is a multifunctional cytokine, derived from bone marrow stromal cells, that stimulates proliferation of stem/progenitor precursor cells in the small intestinal crypts and accelerates recovery of intestinal mucosa after cytoablative therapy. This study evaluates whether IL-11 can improve the function and structure of the small intestine and enhance adaptation in an experimental model of short bowel syndrome. After 90% small bowel resection, 32 Sprague-Dawley rats were divided randomly into eight experimental groups of four animals each. Four groups were treated with IL-11 (125 micrograms/kg twice daily, subcutaneously), and the four control groups were treated with a similar volume (0.1%) of bovine serum albumin (BSA). The animals were weighed daily and were killed on day 2, 4, 6, or 8; remnant small bowel was evaluated for villus height and crypt cell mitosis. The body weight of the animals that received IL-11 was significantly greater at the beginning of postoperative day 4 in comparison to that of the BSA groups (P < .01 during days 5 to 7). The rats that had IL-11 also had significantly greater villus height and crypt cell mitotic rates (P < .05). These observations suggest that IL-11 has a trophic effect on the small bowel during the adaptive phase that follows massive bowel resection and may be useful in the treatment of short bowel syndrome.

Interleukin-11 improves survival and reduces bacterial translocation and bone marrow suppression in burned mice☆

PURPOSE Major burns are associated with a high mortality, an increased rate of bacterial translocation, and bone marrow suppression. This study evaluates the effect of interleukin-11 (IL-11), a bone marrow-derived growth factor on survival, intestinal cytoarchitecture, bacterial translocation, and bone marrow suppression in a highly lethal murine burn model with a lethal dose greater than 50. METHODS C3H/HeJ 8 to 10-week-old mice underwent a standardized 32% total body surface area (TBSA) scald burn using a burn template. Mice were divided equally between groups receiving IL-11 (125 micrograms/kg, twice daily, subcutaneously [SC]) and 0.1% same-volume Bovine Serum Albumin (BSA) (0.2 mL, twice daily, sc). Animals were evaluated for mesenteric lymph node bacterial counts, intestinal mucosal villus height, number of mucosal crypt cell mitoses per 100 crypts, and peripheral platelet and total lymphocyte counts. Survival was calculated to 7 days postburn. RESULTS At 24 hours postburn, IL-11-treated mice had significantly less enteric bacteria cultured from mesenteric lymph nodes (P < .001), increased intestinal crypt cell mitoses (P = .002) and intestinal villus height (P = .002), increased peripheral platelet (P = .002) and lymphocyte counts (P = .004), and an improved survival compared with BSA controls (P = .003). CONCLUSION These data show that IL-11 improves survival, intestinal cytoarchitecture, reduces bacterial translocation, and reduces bone marrow suppression after a 32% TBSA burn in mice. These data imply that IL-11 cytokine therapy may be a useful adjunct in extensive burn injury.

Experience performing 64 consecutive stapled intestinal anastomoses in small children and infants

BACKGROUND/PURPOSE Intestinal anastomosis in children has traditionally been performed using hand-sewn techniques. Little data exist evaluating the efficacy of stapled intestinal anastomoses in the infant and pediatric populations. METHODS A review of a 5-year experience using a mechanical stapler to treat 64 consecutive children requiring intestinal anastomoses was performed. An intestinal stapler was used to complete a side-to-side functional end-to-end anastomosis. Postoperative outcomes and modifications made to the technique were identified. RESULTS Since 2004, 64 children (median age, 3 months; range, newborn to 24 months) underwent procedures requiring intestinal anastomosis. Twenty-six children (41%) were 1 week or less in age. Twenty-seven children (42%) underwent a stoma closure using a stapler. Thirty-seven children (58%) underwent bowel resection and stapled anastomosis in treating a variety of surgical disorders. Complications included wound infection (n = 2) and anastomotic stricture (n = 1). No issues suggesting anastomotic dilatation and subsequent stasis/overgrowth were identified. CONCLUSIONS These results suggest that stapled bowel anastomosis is an effective approach applicable to a variety of surgical diseases in newborns and infants.

Gracilis transposition flap for repair of an acquired rectovaginal fistula in a pediatric patient

Acquired rectovaginal fistulas in the pediatric population are relatively rare but are often difficult to treat. We describe a young girl who acquired a neorectovaginal fistula after a repeat pull-through procedure for Hirschsprungs disease. Durable repair of the fistula was accomplished with a gracilis transposition flap, providing a well-vascularized muscle buttress between the neorectum and vagina. To our knowledge, this is the first report of a gracilis flap in a pediatric patient with an acquired fistula and should be considered for this complication after pull-through for Hirschsprungs as well as for other perineal fistulas such as those acquired after trauma, infection, or in the setting of inflammatory bowel disease.

Pediatric Recipients of Three or More Hepatic Allografts: Results and Technical Challenges

BACKGROUND/PURPOSE Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties. METHODS Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively. RESULTS A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.). CONCLUSIONS The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.

Outcomes Following Two-Stage Surgical Approaches in the Treatment of Pediatric Ulcerative Colitis

INTRODUCTION Surgery for the treatment of ulcerative colitis (UC) can be performed in one-, two-, or three-stage procedures [1]. The more traditional approach is a total proctocolectomy and creation of an ileo pouch-anal anastomosis and diverting stoma at the initial operation, followed by ileostomy closure several weeks later (TIPPA) [1]. An alternative is an initial subtotal colectomy and end ileostomy [2]. In this alternative approach (NIPAA), a completion proctectomy and definitive ileo pouch-anal anastomosis can be performed without a diverting stoma. We hypothesize that functional outcomes following a NIPAA approach when performed in children, in our experience, are likely similar or improved when compared to those treated by TIPAA. METHODS After IRB approval, a review of patients who underwent a two-stage Laparoscopic IPAA from 2004 to 2017 occurred. Data included demographics, diagnosis, surgical intervention time to full diet, level of continence, use of antidiarrheals and complications. RESULTS N = 41 (NIPAA = 14, TIPAA = 27). After establishment of bowel continuity, no significant differences in appetite recovery, continence, or complications were noted. The number of antidiarrheals prescribed were significantly higher in the TIPAA group (p = 0.01). Thirteen patients (31.7%) had pouchitis: 4 NIPAA and 9 TIPAA (p = NS). Of the 41 patients, 11 required subsequent surgery; 2 patients (18.2%) received NIPAA and 9 (81.8%) received TIPAA (p = 0.20). Two TIPAA patients received a diverting ileostomy owing to chronic anal pain and failure to achieve continence. CONCLUSION This study suggests children with medically refractory UC treated by NIPAA or TIPAA have similar outcomes. Minimal differences in overall outcome were noted following either approach. However, NIPAA may reduce reliance on antidiarrheals to achieve satisfactory defecation outcomes. LEVEL OF EVIDENCE III Retrospective comparative study.

Inguinal Hernia in a Preterm Neonate Complicated by Strangulation and Subcutaneous Hernia Sac Rupture

Inguinal hernias are common among preterm neonates, with a relatively high rate of incarceration. We report a unique case of an extremely premature neonate with an enlarging right inguinal hernia that progressed to incarceration, bowel strangulation with necrosis, and subcutaneous rupture of the hernia sac on the 21 day of life requiring urgent laparotomy for reduction and resection of the necrotic small bowel and ostomy creation. The potential morbidity of a missed incarcerated inguinal hernia is high. Neonatologists and pediatricians should consider a low threshold for early surgical referral and evaluation in all pediatric patients. Although incarcerated inguinal hernias are relatively common in preterm neonates, we believe that this is the first report of an inguinal hernia with bowel strangulation and subcutaneous rupture of the hernia sac in a preterm neonate in the literature.

A definition of gentle ventilation in congenital diaphragmatic hernia: a survey of neonatologists and pediatric surgeons.

Abstract Ventilation practices have changed significantly since the initial reports in the mid 1980 of successful use of permissive hypercapnia and spontaneous ventilation [often called gentle ventilation (GV)] in infants with congenital diaphragmatic hernia (CDH). However, there has been little standardization of these practices or of the physiologic limits that define GV. We sought to ascertain among Diaphragmatic Hernia Research and Exploration; Advancing Molecular Science (DHREAMS) centers’ GV practices in the neonatal management of CDH. Pediatric surgeons and neonatologists from DHREAMS centers completed an online survey on GV practices in infants with CDH. The survey gathered data on how individuals defined GV including ventilator settings, blood gas parameters and other factors of respiratory management. A total of 87 respondents, from 12 DHREAMS centers completed the survey for an individual response rate of 53% and a 92% center response rate. Approximately 99% of the respondents defined GV as accepting higher carbon dioxide (PCO2) and 60% of the respondents also defined GV as accepting a lower pH. There was less consensus about the use of sedation and neuromuscular blocking agents in GV, both within and across the centers. Acceptable pH and PCO2 levels are broader than the goal ranges. Despite a lack of formal standardization, the results suggest that GV practice is consistently defined as the use of permissive hypercapnia with mild respiratory acidosis and less consistently with the use of sedation and neuromuscular blocking agents. GV is the reported practice of surveyed neonatologists and pediatric surgeons in the respiratory management of infants with CDH.

Abnormal Fetal Cystic Left Neck Mass

An abnormal fetal cystic left neck mass was found on ultrasonography at 18 weeks gestation in a young woman. Fetal magnetic resonance imaging (MRI) demonstrated a large cystic anterior neck mass (Figure, A, sagittal view, and Figure, B, axial view, on T2-weighted half-Fourier acquired single turbo spin-echo [HASTE] MRI). The tracheoesophageal displacement index (TEDI) was found to be 24 mm. The neonate did well at the cesarean delivery (scheduled owing to the mother’s previous cesarean delivery) and had initial Apgar scores of 7 (1 minute) and 9 (5 minutes). Subsequently, the infant was intubated owing to increased difficulty with milky oral secretions and respiratory distress. Examination of the infant revealed a 5-cm, soft, fluctuant, and mobile neck mass that caused the head to deviate to the right with no cutaneous involvement. On day 2 of life, the mass had an air-fluid level and was markedly hyperintense on axial T2-weighted MRI with fat saturation (Figure, C). It appeared to be predominantly in the retropharyngeal space, anterior to the left carotid artery, and extended to abut themedial aspect of the right carotid sheath.Onday8of life, direct laryngoscopydemonstratedbulging in the left lateralpharyngealand retropharyngealwalls.Whentheneckmasswascompressed,air and fluid escaped froma communicating sinus lateral to the arytenoids in the left pyriform sinus (Figure, D). The mass was excised. A tract was isolated and ligated at the pyriform sinus, deep to the left thyroid lobe. The thyroid lobe was uninvolved. The patient was extubated on day 9 of life and had no problems breathing. What is your diagnosis? 80 mm 80 mm A B