Pierre Lingier

Evaluation of da Vinci Nissen Fundoplication Clinical Results and Cost Minimization

BackgroundA new technical tool was developed and introduced into the therapeutic field of videoscopic surgery—robotic telemanipulation surgery. The aim of this study is to investigate in a prospective randomized trial the feasibility of the Nissen procedure using the da Vinci and to evaluate the benefits and the costs of this new technique compared with the conventional laparoscopic approach.Materials and methodsTwenty patients with gastro-esophageal reflux disease (GERD) were randomized into laparoscopic Nissen versus robot-assisted Nissen fundoplication. All the patients signed an informed consent document. The time data of the procedure, the efficacy of the instruments, the intra-operative incidents, postoperative morbidity, and cost minimization are presented.ResultsNine patients were assigned to the robot, and 11 to the laparoscopic procedure. Both groups were similar in age, male/female ratio, and body mass index. The robot procedure time was significantly longer. The hospital stay and the alimentation day were similar. The number of postoperative complaints was similar after the 1st, 6th, and 12th postoperative months. However, on the 3rd postoperative month, the number of complaints was significantly higher in the robot group. The robot procedure was more expensive with regard to the instrumentation and reusable material, the nursing costs, the investment costs, and the maintenance costs.ConclusionsNo clear advantage of using robotics in the Nissen procedure was observed. The procedure seems to be feasible and safe. The technique is limited because of unadapted instruments. The disadvantages are the high costs and prolonged operative time.

Neonatal hemochromatosis and Martinez-Frias syndrome of intestinal atresia and diabetes mellitus in a consanguineous newborn.

Neonatal hemochromatosis is a heterogeneous disorder of iron metabolism characterized by hepatic failure and marked iron accumulation in liver and extrahepatic tissues. Autosomal recessive transmission is found in most cases. Neonatal hemochromatosis shares cellular features with the adult disease but is clinically and genetically distinct, the causal gene(s) being presently unknown. We report on a newborn from consanguineous parents who presented with multiple congenital anomalies and neonatal hemochromatosis. The syndrome consisted of intra-uterine growth retardation, intestinal atresia, gallbladder aplasia and diabetes mellitus, and fitted with the diagnosis of Martinez-Frias syndrome, a very rare autosomal recessive phenotype, the gene of which remains to be identified. We suggest that neonatal hemochromatosis may be part of the Martinez-Frias syndrome. Molecular analyses in this and other reported patients with the Martinez-Frias syndrome should shed light on gut development and iron metabolism.

Sonographic prenatal diagnosis of malpositioned stomach as a feature of uncomplicated intestinal malrotation

Intestinal malrotation is a developmental anomaly affecting the position and peritoneal attachments of the small and large intestines during fetal life. Most often the diagnosis is established in the first year of life on the basis of abdominal pain and bile-stained vomiting secondary to bowel obstruction. The antenatal diagnosis can be suggested by identification of the complications such as bowel dilatation, ascites or meconium peritonitis. We describe two cases of isolated antenatal gastric malposition without any other associated anomaly that were confirmed after birth to be due to intestinal malrotation. We suggest that such an antenatal finding should alert the paediatrician to close clinical follow-up and prompt the diagnosis and surgical treatment in case of abdominal pain and/or bilious vomiting.

Gastric perforation due to mucormycosis after heart-lung and heart transplantation.

BACKGROUND Gastrointestinal complications are a well-documented source of morbidity and mortality after heart and lung transplantation. METHODS We report on two patients who presented with gastric perforation caused by mucormycosis during the first 2 months after heart-lung and heart transplantation. RESULTS In the first patient, the clinical presentation was insidious and the diagnosis was made at an advanced stage of the disease. Despite surgery and aggressive antifungal treatment, the patient died. In the second patient, the diagnosis was made promptly, but despite antifungal treatment, he presented with gastric perforation within a week. CONCLUSIONS These cases illustrate that fungal invasive disease may be a cause of early gastrointestinal perforation after solid organ transplantation.

An unusual presentation of a cystic duplication of the sigmoid colon entirely lined with squamous epithelium.

Alimentary tract duplications are rare congenital malformations that occur most commonly in the jejunoileal part of the gastrointestinal tract. Management of this pathologic condition is usually drawn up. We report a case of descending colonic communicating duplication in which clinical presentation and anatomopathologic results were unexpected. A slightly echogenic abdominal mass reaching 72 x 36 mm in the left flank was diagnosed in a female fetus during the third trimester ultrasound examination. At birth, volume of the mass rapidly evolved, and despite no intestinal obstruction was observed by compression of the adjacent gastrointestinal tract, abdomen was distended. Abdominal plain film showed a large air collection, and the barium enema demonstrated a slight leak of contrast in the aerated mass, suggesting a communication with the sigmoid colon. No other abnormalities were seen. The patient underwent surgery in emergency. The mass was then totally excised through an antimesenteric resection of the tubular tract joining cystic mass and sigmoid colon. A lateral suture of the colon was subsequently performed. The wall of the duplication is usually composed of a smooth muscle layer covered by an epithelium, mostly of intestinal type. Herein, we describe a descending colonic duplication completely lined with nonkeratinizing squamous epithelium. Therefore, the association of a colonic mucosa (of endodermic origin) and a squamous epithelium (derived from the ectoderm) in our case is an interesting finding and is not explained by the various theories. Furthermore, the clinical characteristics, diagnosis, and treatment of intestinal duplications are discussed with regard to literature.

Prenatal diagnosis of atypical gastroschisis

Perinatal ultrasonography is very important for thedetection, identification, and follow-up of abdominalwall defects. The ability to distinguish between typesof abdominal wall defects and reach a correct diag-nosis is not always easy. We present two unusualcases of gastroschisis with change in the ultrasono-graphic appearance as pregnancy progressed anddiscuss perinatal management.

In Utero Urinary Bladder Rupture: a Case Report

Abstract We report a case of foetal urinary bladder rupture due to posterior urethral valves. A megacystis was diagnosed in a male foetus during routine second trimester ultrasound examination. The diagnosis of bladder rupture was made as, one week later, the bladder became undetectable with the appearance of ascites. During the follow-up, no oligohydramnios developed and intercurrent ascites resolved spontaneously. There are three described mechanisms releasing bladder hyperpressure: bladder diverticles, unilateral vesicoureteral reflux and bladder rupture. In this case, another mechanism might be involved: a patent urachus. The urethral valves were resected and no other surgical treatment was needed. The renal function remained normal. No long-term vesical follow-up of this pathology is available in the literature.

Chromogranin A(210–301) is the major form of pancreastatin-like material in human gut extracts and endocrine tumors

A radioimmunoassay of human pancreastatin was developed using a rabbit antiserum that selectively recognized the C-terminal amidated end of the peptide, and it was used for the identification of the molecular forms of pancreastatin in human gut (stomach, duodenum, small intestine, colon) and endocrine tumor extracts (liver metastasis of a gastrinoma and a medullary carcinoma of thyroid, one nonsecreting pancreatic tumor, one recurrence of a gut carcinoid, one vipoma and one insulinoma). In all gut extracts, a gel filtration chromatography revealed the presence of three peaks of pancreastatin-like immunoreactivity. The predominant form eluted with an apparent molecular weight higher than that of pancreastatin. This form was also predominant in the endocrine tumors analyzed, except in the insulinoma, where a lower molecular weight form predominated. The high molecular form was further purified from a liver metastasis of a gastrinoma. The pancreastatin-like immunoreactivity eluted in all the chromatographical systems (reverse-phase, ion exchange) as a single peak that was finally purified to homogeneity and sequenced. The sequence of the first 29 N-terminal amino acids was obtained unambiguously and corresponded to the sequence 210-238 of chromogranin A. Considering the selectivity of the assay used for peptide identification, this major form was identified as the fragment 210-301 of chromogranin A. It is likely that the predominant form of pancreastatin in human gut extracts and noninsular tumors is a 92 amino acid peptide.

Arterial to End-Tidal Carbon Dioxide Tension Differences in Infants andChildren

Background: Several reports have demonstrated substantial mean differences between arterial carbon dioxide tension (PaCO2) and end-tidal carbon dioxide tension (ETCO2) in children under anesthesia. Aim: We explored the importance of the (a-ET) PCO2 gradient in a pediatric population receiving general anesthesia, with special attention to the relative effects of age and weight. Methods: After induction of general anesthesia, 129 children, ASA I or II, and between 1 day and 15 years old, had an endotracheal tube placed and mechanical ventilation initiated. After reaching a steady-state ETCO2, an arterial blood sample was obtained and the PaCO2 measured. Results: The mean (a-ET) PCO2 was 1.6 ± 4.3 mmHg for the entire pediatric population. There was a significant negative correlation between (a-ET) PCO2 and age and weight (r =-0.42, P<0.0001 and -0.44, P<0.0001, respectively). The calculated (a-ET) PCO2 varied from 6.8 ± 6.9 mmHg in neonates to 4.8 ± 4.4 mmHg in children aged between 2 and 4 months. After 8 months, (a-ET) PCO2 was less than 2 mmHg. A negative (a-ET) PCO2 of -1.8 ± 1.4 mmHg was observed in 44 (34%) patients with an age range between 4 to 8 years. Conclusion: Our results indicate that ETCO2 gives an excellent value of the PaCO2 in children more than 8 months. However, PaCO2 cannot be extrapolated accurately from ETCO2 in babies less than 4 months or weighing less than 5 kg who are mechanically ventilated via an endotracheal tube. Nevertheless, ETCO2 remains a key monitoring as a trend monitor and mandatory to identify the tracheal position of the tube.

Outcomes of kidney transplantations in children weighing 15 kilograms or less: a retrospective cohort study

Kidney transplantation (KT) is often delayed in small children because of fear of postoperative complications. We report early‐ and long‐term outcomes in children transplanted at ≤15 kg in the two largest Belgian pediatric transplant centers. Outcomes before (period 1) and since the introduction of basiliximab and mycophenolate‐mofetil in 2000 (period 2) were compared. Seventy‐two KTs were realized between 1978 and 2016: 38 in period 1 and 34 in period 2. Organs came from deceased donors in 48 (67%) cases. Surgical complications occurred in 25 KTs (35%) with no significant difference between the two periods. At least one acute rejection (AR) occurred in 24 (33%) KTs with significantly less patients experiencing AR during period 2: 53% and 12% in period 1 and, period 2 respectively (P < 0.001). Graft survival free of AR improved significantly in period 2 compared with period 1: 97% vs. 50% at 1 year; 87% vs. 50% at 10 years post‐KT (P = 0.003). Graft survival tended to increase over time (period 1: 74% and 63% at 1 and 5 years; period 2: 94% and 86% at 1 and 5 years; P = 0.07), as well as patient survival. Kidney transplantation in children ≤15 kg remains a challenging procedure with 35% of surgical complications. However, outcomes improved and are nowadays excellent in terms of prevention of AR, patient and graft survival.