Sathyaprasad Burjonrappa

Rapid Communication: Laparoscopic Anderson-Hynes Dismembered Pyeloplasty Using the da Vinci™ Robot: Technical Considerations

PURPOSE To present our initial experience with laparoscopic pyeloplasty utilizing the da Vinci robot for upper tract reconstruction. CASE REPORT A four-port transperitoneal approach was used in a 73-year-old man. The ureteropelvic (UPJ) obstruction was identified with a crossing vessel. After dismemberment of the UPJ, the renal pelvis was trimmed and reconstructed using the da Vinci robot. The total operative time was 5 hours; the time spent for reconstruction was 45 minutes. Blood loss was <150 mL. The postoperative analgesic requirement was 8 mg of morphine and 25 mg of hydrocodone. There were no intraoperative or postoperative complications. CONCLUSION The da Vinci robot can serve as a vital surgical tool during pyeloplasty with extensive reconstruction.

Type A esophageal atresia: a critical review of management strategies at a single center

PURPOSE The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies. METHODS All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied. RESULTS Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally. CONCLUSIONS Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.

Mucin expression profile in Barrett's, dysplasia, adenocarcinoma sequence in the esophagus

BACKGROUND The molecular events that accompany the progression to adenocarcinoma (ADC) of the esophagus are poorly understood. Aberrant mucin receptor expression can contribute to increased cell growth and metastatic ability. AIM The aim of this study was to establish a pattern for mucin (MUC) gene expression in the esophageal mucosa under normal and pathological conditions. SETTING University Hospital Cancer Center Laboratory. Archived tissue samples studied in a retrospective fashion. MATERIALS AND METHODS Tissue samples were obtained from the archives of patients with histological evidence of Barretts esophagus (BE) progressing to ADC. Immunohistochemical analysis was performed using mouse monoclonal antibodies for MUC1, MUC2, MUC5AC, MUC6. Semiquantitative scoring of histological staining was performed using a linear scoring system: 0-staining absent; 1-staining in 0-25%; 2-staining in 25-50%; and 3-staining in 50-75% of the epithelium. The Binomial test was used to explore trends and differences in frequency of mucin expression along the pathological sequence. RESULTS Only mild superficial staining of MUC1 was seen in normal squamous epithelium. MUC1 and MUC2 were uniformly expressed in all samples (7/7) of BE and dysplasia (P=0.008). MUC1 expression was upregulated (7/7) in progression to adenocarcinoma (P=0.008). The secretory mucins, MUC5AC and MUC6 showed a decrease in expression with progression from BE to dysplasia to ADC (P< 0.05). CONCLUSIONS Downregulation of MUC5AC and MUC6 decreases mucosal protection against gastric acid. Increasing MUC1 expression is associated with progression from dysplasia to ADC. Upregulation of MUC2 reflects intestinal metaplasia in BE.

Congenital mesenteric defect: Description of a rare cause of distal intestinal obstruction in a neonate.

INTRODUCTION Internal hernias are a rare cause of bowel obstruction in the neonate and present with bilious vomiting. Newborns may be at risk of loss of significant length of bowel if this rare condition is not considered in the differential diagnosis of bilious emesis. PRESENTATION OF CASE We report a case of a twin with an internal hernia through a defect in the ileal mesentery who presented with neonatal bowel obstruction. The patient had a microcolon on the contrast enema suggesting that the likely etiology was an intra-uterine event most likely a vascular accident that prevented satisfactory meconium passage into the colon. DISCUSSION An internal hernia is rarely considered in the differential diagnosis of distal bowel obstruction in a neonate with a microcolon. Congenital trans-mesenteric hernias constitute only 5-10% of internal hernias. True diagnosis of trans-mesenteric hernias is difficult due to lack of specific radiology or laboratory findings to confirm the suspicion. CONCLUSION When clinical and radiological findings are not classical, rare possibilities such as an internal hernia must be considered in the differential diagnosis, to avoid catastrophic bowel loss.

A Review of Enteral Strategies in Infant Short Bowel Syndrome: Evidence-based or NICU Culture?

INTRODUCTION Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based. MATERIALS AND METHODS A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied. RESULTS We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions. DISCUSSION There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.

What is the incidence of Barrett's and gastric metaplasia in esophageal atresia/tracheoesophageal fistula (EA/TEF) patients?

OBJECTIVE Aim of the study was to document the incidence of gastric and intestinal metaplasia (Barretts esophagus) in a closely followed group with EA/TEF, determine the efficacy of pH probe studies in diagnosing reflux and, moreover, to determine the lag period between the development of gastroesophageal reflux disease (GERD) and metaplasia. MATERIALS AND METHODS Patients who underwent EA/TEF correction were followed up over an 18-year period (1990-2009) with regular pH probe and endoscopy investigations. Biopsies were performed at 3 year intervals to evaluate for metaplastic changes in the esophageal epithelium. The interval between esophageal atresia correction and the development of erosive esophagitis, gastric metaplasia and Barretts esophagus was determined. The development of complicated GERD was statistically correlated to age at detection. RESULTS 51 patients (28 male) underwent EA/TEF correction during the study period. The ages of the children followed up ranged from 7 months to 19 years. There were 5 Type A, 44 Type C and 2 Type D fistulas. 37 patients (5 Type A, 31 Type C, 1 Type D) had documented reflux and 14 did not. 17 (46%) of the patients with reflux underwent an anti-reflux operation. 4 of the 17 underwent 2 or more anti-reflux procedures. 21 patients had pH probe studies positive for reflux, 3 had negative pH probe studies after an anti-reflux operation. 18 of the 37 patients with reflux (about 50%) needed esophageal dilatation for either anastamotic or non-anastamotic strictures. Only 4/14 (28.5%) patients without reflux underwent dilatations and only in their first year of life (p=NS). 15 patients had mucosal abnormalities in endoscopic biopsies. 8 patients had gastric metaplasia and 1 patient had Barretts esophagus. The mean age in the group with metaplasia (gastric and intestinal) was 13 years, which was significantly different from the mean age of the group (5.2 years) without mucosal changes (p<0.001). 2 patients with normal pH probe studies had metaplasia on biopsies. CONCLUSION Metaplasia arises in about 15% of patients with EA/TEF. The lag time to developing metaplasia from the time of initial surgical correction is about 10 years. Endoscopy and biopsies are the best way of detecting mucosal changes.

The role of amniotic fluid in influencing neonatal birth weight

Objective:We studied 123 neonates with atresias of the gastrointestinal tract at different levels to assess the role of amniotic fluid in the growth and development of the gastrointestinal tract. Our hypothesis was that significant differences in birth weight between groups otherwise comparable would suggest an intrauterine nutritive role for amniotic fluid. Our second hypothesis was that there is a trophic role of amniotic fluid on intestinal epithelium affecting its functional maturity. Establishing earlier tolerance of enteral nutrition in neonates with distal as compared with proximal atresias would support this hypothesis.Study Design:Overall, 123 neonates from a single institution, with duodenal atresia (DA), jejuno-ileal (JIA) and colonic atresia (CA), were separated into three groups. Birth weight, gestational age, associated anomalies and duration of total parenteral nutrition intake were recorded. Neonates with multiple atresias and gastroschisis were excluded from analysis. Statistical analysis of differences between groups was carried out using analysis of variance (ANOVA) for independent samples. Post-ANOVA pairwise comparisons were carried out using the Tukey-HSD test.Result:Fifty-four DAs, 62 JIAs and seven CAs were included. The mean birth weight, 2380.5 g (s.d. 988) in DA, 2814 g (s.d. 755) in JIA and 3153 g (s.d. 527) in CA were significantly different between groups (P=0.011). The Tukey-HSD test showed that DA<JIA<CA was also significant (P<0.01). The mean gestational age (Tukey-HSD test, P=not significant (NS)) and presence of associated anomalies (Wilcoxson, P=0.08) did not differ significantly among the groups. Total parenteral nutrition was stopped at a mean period of 18 days in DA, 15.6 days in JIA and 15.6 days in CA (Tukey-HSD, P=NS).Conclusion:Proximal atresias have a significantly lower birth weight than atresias distal in the gastrointestinal tract. This cannot be explained on the basis of gestational age or associated anomalies. Although not conclusive, this study implies an intrauterine nutritive role for amniotic fluid. Further studies are needed to prove the trophic effects of amniotic fluid on the gut.

Teaching single-incision laparoscopic appendectomy in pediatric patients.

There is a significant learning curve in acquiring singleincision laparoscopic appendectomy skills in pediatric patients.

Review of nutritional assessment and clinical outcomes in pediatric surgical patients: Does preoperative nutritional assessment impact clinical outcomes?

INTRODUCTION Malnourished adult patients who undergo surgical procedures tend to have worse clinical outcomes compared to well-nourished patients. In the pediatric surgical patient, nutritional assessment is considered a critical aspect of the initial evaluation, but a correlation between preoperative malnutrition and poor surgical outcomes is not clear. We hypothesized that an evidence-based review would reveal that measures of nutritional assessment in children would not correlate pre-operative malnutrition with poor surgical outcomes. MATERIALS AND METHODS A search of major English language medical databases (Medline, Cochrane, SCOPUS) was conducted for the key words nutritional assessment, pediatric, children, surgery, and outcomes. All methods of nutritional assessment in pediatric surgery were evaluated for their relevance and relation to outcomes after surgery. The Oxford Center for Evidence Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied. RESULTS 35 articles were evaluated after an exhaustive literature search, of which six met inclusion criteria for this review. There is a paucity of high quality evidence correlating preoperative malnutrition in pediatric surgical patients with clinical outcomes. Factors contributing to the low level of evidence include a lack of high quality randomized controlled trials, a lack of consensus in study design and methods, and utilization of incongruous methods of nutritional assessment, including methods that may be unproven in the study population. CONCLUSION Larger multi center randomized studies are needed to offer higher level of evidence to support nutritional intervention prior to major elective pediatric surgery.

Laparoscopic orchidopexy: the easy way to go

BACKGROUND/PURPOSE Intraabdominal testes represent less than 10% of cryptorchid testicles, and yet, they are the most challenging to correct. In the last 15 years, the two-stage Fowler-Stephens orchidopexy has gained popularity. The traditional approach includes laparoscopic or open clipping of the testicular vessels (first stage) and open inguinal orchidopexy (second stage). We present our experience with 2-stage orchidopexy with both stages done through a laparoscopic approach. MATERIALS AND METHODS Over a recent 5-year period, we reviewed patients operated for intraabdominal testis using a two-stage laparoscopic orchidopexy with a minimum of 1-year follow-up. In this study, success is defined as a nonatrophic, intrascrotal testis. Fifteen patients met the inclusion criteria, and none were lost to follow-up. RESULTS In the 15 patients, 11 had a unilateral intraabdominal testis, and 4 had bilateral cryptorchidism, with one of the 2 testes intraabdominal. The first stage was done at a mean age of 32 months, and the average time between the two stages was 9.7 months. All procedures (31) were done on an outpatient basis. Only 2 complications occurred, one scrotal hematoma and one redo first stage because of unsuccessful clipping noted at the time of planned second stage. The success rate is 93.3% (14/15). All testicles are intrascrotal, and all but 1 have maintained preoperative volume. CONCLUSION Two-stage laparoscopic orchidopexy is a fairly easy surgical procedure with minimum morbidity and high short term success rate. A larger cohort of patients with long-term follow-up is needed to substantiate these findings.