Sanjeev Khurana

Comparison of intraabdominal abscess formation after laparoscopic and open appendicectomies in children

AIM Although laparoscopic appendicectomy (LA) is an accepted alternative to the open appendicectomy (OA) approach, it has been suggested that there is a higher incidence of intraabdominal abscesses (IAAs). Our aim was to determine the incidence of IAA in 3 pediatric surgical centers routinely practicing both techniques. METHODS Data were collected retrospectively for pediatric patients undergoing LA or OA over an 8-year period. Analysis included IAA formation, appendicitis complexity, radiologic/histologic investigations, grade of surgeon, and wound infection. MAIN RESULTS A total of 1267 appendicectomies were performed (514 LAs and 753 OAs). There was no difference between the incidences of IAA (LA, 3.9% [19/491] vs OA, 3.9% [28/714]; P = 1.0). The incidence of IAA was increased in those with complicated appendicitis (34/375 [9.1%] vs 13/830 [1.6%]; P ≤ .0001). There was an increased proportion of those with complicated appendicitis in the LA group (182/491 [37.1%] vs 193/714 [27.0%]; P = .0002). Surgical trainees were more likely to be the primary surgeon in the OA group (79% vs 63%; P = .0001), although the incidence of IAA did not correlate with grade of surgeon. There was no significant difference in incidence of wound infection between groups (LA, 4.6% [8/173] vs OA, 2.5% [18/377]; P = .93). CONCLUSION This large retrospective study shows that the technique of appendicectomy does not appear to affect the incidence of IAAs. Patients with complicated appendicitis are more likely to develop an IAA regardless of technique.

The epigenetic signature of CFTR expression is co-ordinated via chromatin acetylation through a complex intronic element

The CFTR (cystic fibrosis transmembrane conductance regulator) gene is a tightly regulated and differentially expressed transcript in many mucosal epithelial cell types. It appears that DNA sequence variations alone do not explain CFTR-related gastrointestinal disease patterns and that epigenetic modifiers influence CFTR expression. Our aim was to characterize the native chromatin environment in cultured cells for intestinal CFTR expression by determining the relationship between histone acetylation and occupation of CFTR by multiple transcription factors, through a common regulatory element. We used HDAC (histone deacetylase) inhibition and ChIP (chromatin immunoprecipitation) analyses to define regions associated with acute acetylation of histone at the CFTR locus. We identified a region within the first intron associated with acute acetylation of histone H4 as an epigenetic signature corresponding to an intestine-specific enhancer element for CFTR. DHS (DNase I-hypersensitivity) assays and ChIP were used to specify control elements and occupation by regulatory factors. Quantitative ChIP procedures indicate that HNF1alpha (hepatic nuclear factor 1alpha) and Cdx2 (caudal homeobox protein 2) occupy and regulate through a novel intronic enhancer element of CFTR and that Tcf4 (T-cell factor 4) overlaps the same DNA element. RNAi (RNA interference) of Tcf4 and HNF1alpha decreased intestinal cell CFTR expression, identifying these as positive regulatory factors and CFTR as a target for Wnt signalling. We have linked the acetylation signature of nucleosomal histones to active intestinal CFTR expression and occupation by transcription factors HNF1alpha, Cdx2 and Tcf4 which converge to modify chromatin architecture. These studies suggest the therapeutic potential of histone modification strategies, such as inhibition of HDAC activity, to treat CFTR-associated disease by selectively enhancing CFTR expression.

Pneumoperitoneum for neonatal laparoscopy: how safe is it?

We present the case of a 3 day old term neonate who experienced a cardiopulmonary arrest during creation of pneumoperitoneum for laparoscopic repair of duodenal atresia. The arrest was thought likely to have occurred as a result of a gas embolism. We discuss the features of the neonatal circulation which may predispose neonates to embolic phenomena during laparoscopic procedures, and the potential benefit of priming the insufflation apparatus with carbon dioxide. The possibility of gas embolism should be considered when contemplating laparoscopic surgery in this patient group.

Robotic surgery in children: adopt now, await, or dismiss?

The role of robot-assisted surgery in children remains controversial. This article aims to distil this debate into an evidence informed decision-making taxonomy; to adopt this technology (1) now, (2) later, or (3) not at all. Robot-assistance is safe, feasible and effective in selected cases as an adjunctive tool to enhance capabilities of minimally invasive surgery, as it is known today. At present, expectations of rigid multi-arm robotic systems to deliver higher quality care are over-estimated and poorly substantiated by evidence. Such systems are associated with high costs. Further comparative effectiveness evidence is needed to define the case-mix for which robot-assistance might be indicated. It seems unlikely that we should expect compelling patient benefits when it is only the mode of minimally invasive surgery that differs. Only large higher-volume institutions that share the robot amongst multiple specialty groups are likely to be able to sustain higher associated costs with today’s technology. Nevertheless, there is great potential for next-generation surgical robotics to enable better ways to treat childhood surgical diseases through less invasive techniques that are not possible today. This will demand customized technology for selected patient populations or procedures. Several prototype robots exclusively designed for pediatric use are already under development. Financial affordability must be a high priority to ensure clinical accessibility.

Successful treatment of disseminated mucormycosis in a neutropenic patient with T-cell acute lymphoblastic leukaemia

Mucormycosis is a rare angioinvasive fungal infection, more commonly seen in immunosuppressed patients, with reported mortality rates of 95% in disseminated disease. We present a case report of a patient with T-cell acute lymphoblastic leukaemia who developed disseminated infection with mucormycosis (involving the pancreas, left occipital lobe, right lower lobe of lung, appendix and right kidney) after having completed induction and consolidation chemotherapy. Growth of Lichtheimia corymbifera was initially isolated following a right pleural tap with fungal elements identified repeatedly on subsequent pathology specimens. Following radical surgical debridement and concurrent treatment with combination antifungal therapy, the patient survived. This case demonstrates that aggressive multisite surgical de-bulking of disseminated fungal foci, in conjunction with combination antifungal therapy and reversal of immunosuppression, can result in survival despite the grave prognosis associated with disseminated mucormycosis.

Kasai hepatoportoenterostomy in South Australia: a case for ‘centralized decentralization’

Recent follow‐up studies have demonstrated significant improvement in overall survival as well as survival with native liver following geographic centralization of services to three centres in the UK. However, this model has not been replicated in countries with relatively low population density such as Australia and Canada.

Fast-track surgery for uncomplicated appendicitis in children: a matched case–control study

Standardized post‐operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case–control study investigates the effect of a multidisciplinary criteria‐led discharge protocol for uncomplicated appendicitis in children.

Presentation of an umbilical cord cyst with a surprising jet: a case report of a patent urachus.

We report a baby with an unusual true umbilical cord cyst detected at 12 weeks gestation which as the pregnancy progressed became increasingly difficult to distinguish from a pseudocyst of the umbilical cord. Concern of the possibility of cord compression/cord accident led to an elective caesarean section being performed at 35+ week’s gestation with delivery of a healthy female infant weighing 2170g. At birth the cyst ruptured and the resultant thickened elongated cord was clamped accordingly. After the cord clamp fell off at 5 days post delivery an elongated umbilical stump was left behind from which a stream of urine surprisingly jetted out from the umbilicus each time the baby cried. A patent urachus was confirmed on ultrasound and the umbilical jet of urine resolved at 4 weeks post delivery after treatment of an Escherichia coli urinary tract infection. At 11 weeks post delivery a laparoscopic excision of the urachus was successfully performed. The baby, now 18 months of age, continues to thrive without incident.

Australian Experience of Total Pancreatectomy and Islet Auto Transplant (TPIAT) Utilizing a Remote Isolation Center

Introduction In 2015 we performed the first TPIAT in Australia on a 7 year old paediatric patient suffering hereditary chronic pancreatitis due to a PRSS1 mutation. We have since performed a further 4 TPIAT procedures, 2 paediatric and 2 adult recipients. All 5 TPIAT procedures were performed in Adelaide, South Australia at the Women’s and Children’s Hospital (paediatric patients) or the Royal Adelaide Hospital (adult patients). The islet isolation procedure was performed at a remote isolation center, St Vincent’s Institute (SVI), Melbourne Victoria. SVI is a 1hr15min commercial flight from Adelaide or approximately 470 miles by road. Following isolation, the islets were infused back into each patient on the same day in Adelaide. Materials and Methods In the first 2 patients a total pancreatectomy, splenectomy, cholecystectomy, and biliary and enteric reconstruction was performed. In patients 3-5 the spleen was spared during the total pancreatectomy. Once removed, the pancreas was placed in preservation solution and escorted from Adelaide to Melbourne by commercial airline. Pancreatic digestion and islet isolation were performed using Serva enzyme and standard protocols. Islet infusion into the liver was performed by cannulation of the portal vein with concomitant portal vein pressure monitoring. Results The cold ischaemic time for all 5 pancreas was similar, ranging from 5hr to 5hr21min. The pancreas weights varied significantly, however this did not correlate with islet yield. Total IEQ ranged from 28,254 to 653,222 and the time from placing the islets into transplant bags through to infusion into the recipient was relatively consistent, ranging from 4-5hrs. To date, patients 1 & 3 have ceased all pre-operative pain medication and patient 4 has significantly reduced his opiate usage and is currently undergoing a controlled withdrawal and detoxification program with medical guidance to cease the remaining analgesia. Patient 5 the most recent TPIAT is in the process of weaning off her pre-operative analgesia and patient 2 suffered complications following TPIAT and is deceased. All 4 surviving patients are c-peptide positive with daily insulin requirements ranging from 10-20U and HbA1c levels of 5-8. Conclusion We have successfully completed a pilot study involving 5 patients undergoing TPIAT for the management of chronic pancreatitis. All 5 isolations were performed at a facility remote to the hospital where the total pancreatectomy and subsequent islet infusion was performed. All surviving recipients have experienced a reduction or complete resolution of their chronic pain following TPIAT with two patients no longer requiring any form of analgesia. They are all c-peptide positive, requiring minimal doses of exogenous insulin with excellent management of their diabetes. Recently, we secured additional funding to perform 6 more TPIATs with the long-term goal of establishing TPIAT as a government funded procedure for the treatment of chronic pancreatitis. The Hospital Research Foundation South Australia. MedVet Sciences South Australia. Women’s and Children’s Hospital. Table. No title available.

First Report of Successful Total Pancreatectomy and Islet Autotransplant in Australia

To the Editor:We present the first total pancreatectomy and islet autotransplant (TP-IAT) performed in Australia in a child with hereditary pancreatitis. Collaboration with interstate and international expertise enabled this procedure. The 7-year-old boy had a severely fibrosed pancreas but has achi