Shogo Seo

Rectal mucosal dissection commencing directly on the anorectal line versus commencing above the dentate line in laparoscopy-assisted transanal pull-through for Hirschsprung's disease: Prospective medium-term follow-up.

BACKGROUND In 2007, we began using the anorectal line (ARL) as the landmark for commencing rectal mucosal dissection (RMD) instead of the dentate line (DL) during laparoscopy-assisted transanal pull-through (L-TAPT) for Hirschsprungs disease (HD). We conducted a medium-term prospective comparison of postoperative fecal continence (POFC) between DL and ARL cases to follow our short-term study. METHODS POFC is assessed by scoring frequency of motions, severity of staining, severity of perianal erosions, anal shape, requirement for medications, sensation of rectal fullness, and ability to distinguish flatus from stool on a scale of 0 to 2 (maximum: 14). RESULTS Patient demographics were similar for ARL (2007-2014: n=33) and DL (1997-2006: n=41). There were no intraoperative complications and 2 cases of postoperative colitis in both ARL (6.1%) and DL (4.9%). Mean annual medium-term POFC scores for the 4-7 term of this study were consistently better in ARL: 9.7±1.4*, 10.1±1.6*, 10.6±1.6, and 11.3±1.4* in ARL and 8.6±1.5, 9.1±1.6, 9.8±1.9, 10.0±1.6 in DL (*: p<0.05). CONCLUSIONS Medium-term POFC is better when the ARL is used as the landmark for RMD during L-TAPT for HD.

Are prophylactic anti-reflux medications effective after esophageal atresia repair? Systematic review and meta-analysis

PurposeGastroesophageal reflux after surgical repair of esophageal atresia (EA) can be associated with complications, such as esophageal stricture. Recent guidelines recommend prophylactic anti-reflux medication (PARM) after EA repair. However, the effectiveness of PARM is still unclear. The aim of this study was to review evidence surrounding the use of PARM in children operated for EA.MethodsWe performed a systematic review and meta-analysis. We searched Medline, EMBASE, and the Cochrane Databases from inception until the end of 2016 for comparative studies of PARM versus no PARM (control). Primary outcome was postoperative esophageal stricture. Quality of evidence was assessed using GRADE system.ResultsWe identified four observational studies that focused on esophageal stricture as an outcome. A total of 362 patients were included in meta-analysis. There was no significant difference in esophageal stricture rates between PARM and control (OR = 1.14; 95% CI = 0.61–2.13; p = 0.68; I2 = 38%). The quality of the evidence was very low, due to lack of precision as a consequence of small study sizes.ConclusionsOur results indicate that PARM does not reduce the incidence of esophageal stricture after EA repair. Future well-controlled prospective studies are needed to obtain higher quality evidence.

Liver damage, proliferation, and progenitor cell markers in experimental necrotizing enterocolitis

BACKGROUND Necrotizing enterocolitis (NEC) is a disease known to cause injury to multiple organs including the liver. Liver regeneration is essential for the recovery after NEC-induced liver injury. Our aim was to investigate hepatic proliferation and progenitor cell marker expression in experimental NEC. METHODS Following ethical approval (#32238), NEC was induced in mice by hypoxia, gavage feeding of hyperosmolar formula, and lipopolysaccharide. Breastfed pups were used as control. We analyzed serum ALT level, liver inflammatory cytokines, liver proliferation markers, and progenitor cell marker expression. Comparison was made between NEC and controls. RESULTS Serum ALT level was higher in NEC (p<0.05). The mRNA expression of inflammatory cytokines in the liver was also higher in NEC (IL6: p<0.05, TNF-α: p<0.01). Conversely, mRNA expression of proliferation markers in the liver was lower in NEC (Ki67; p<0.01, PCNA: p<0.01). LGR5 expression was also significantly decreased in NEC as demonstrated by mRNA (p<0.05) and protein (p<0.01) levels. CONCLUSIONS Inflammatory injury was present in the liver during experimental NEC. Proliferation and LGR5 expression were impaired in the NEC liver. Modulation of progenitor cell expressing LGR5 may result in stimulation of liver regeneration in NEC-induced liver injury and improved clinical outcome. LEVEL OF EVIDENCE Level IV.

Duhamel and Transanal Endorectal Pull-throughs for Hirschsprung' Disease: A Systematic Review and Meta-analysis

Abstract Aim The Duhamel pull‐through and transanal endorectal pull‐through (TEPT) are commonly used for the treatment of Hirschsprungs disease (HD). To date, there has been no meta‐analysis evaluating postoperative outcomes following Duhamel pull‐through and TEPT. The purpose of this meta‐analysis was to compare patient outcome after Duhamel pull‐through and TEPT for HD. Materials and Methods Original articles published between 1998 and 2016 were identified using the MEDLINE database. Studies comparing Duhamel pull‐through and TEPT were included. Outcomes evaluated included incidence of postoperative constipation, incontinence/soiling, enterocolitis, anastomotic stricture, and leak. We analyzed dichotomous variables by estimating odds ratios (OR) with 95% confidence intervals (CI) and continuous variables using the weighted mean difference with 95% CI. The meta‐analysis was done using RevMan 5.3. Result There were no randomized controlled trials. Seven observational clinical studies were included, comprising 260 cases of Duhamel pull‐through and 170 cases of TEPT. Anastomotic stricture (OR = 0.10; 95%CI 0.02‐0.48; p = 0.004) was lower following Duhamel pull‐through than TEPT. There were no significant differences in the incidence of postoperative incontinence/soiling and anastomotic leak. After TEPT, postoperative constipation seems to be lower and enterocolitis higher compared with those after Duhamel pull‐through; however, these differences are not significant when the follow‐up period is equal between groups. Conclusion The Duhamel pull‐through seems to be associated with lower incidence of anastomotic stricture compared with TEPT. The effects of the two analyzed operative techniques on constipation and enterocolitis remain unclear. The quality of evidence supporting the above findings is suboptimal, indicating the need for prospective studies.

Pneumoperitoneum and hemodynamic stability during pediatric laparoscopic appendectomy.

BACKGROUND Conventional pneumoperitoneum (CP) and automatically maintained pneumoperitoneum using AirSeal Intelligent Flow System (AiFS) were compared during pediatric laparoscopic appendectomy (LA) using intraperitoneal pressure (IPP) and hemodynamic parameters. METHODS A prospective review of 39 children aged 3-14years who had standard 3-trocar LA was performed. Pneumoperitoneum was either AiFS (n=18) or CP (n=21) according to the surgeons preference. IPP during insertion of trocars in all subjects was initially 8-10mmHg, which was reduced to 5mmHg then maintained until LA was completed. Data were collected every 5min during pneumoperitoneum. RESULTS Subject demographics were similar for both groups. During pneumoperitoneum, average IPP (AiFS: 7.9; CP: 9.0mmHg), average systolic blood pressure (AiFS: 100.4; CP: 106.9mmHg), and average end-tidal CO2 (EtCO2; AiFS: 35.7; CP: 38.5mmHg) were significantly different (p<.05, respectively), while pulse (AiFS: 92.1; CP: 96.4bpm), oxygen saturation (AiFS: 98.8; CP: 98.8%), body temperature (AiFS: 37.2; CP: 37.4), urine output (AiFS: 2.7; CP: 2.4mL/kg per hour), operative time (AiFS: 72.2; CP: 76.2mins), blood loss (AiFS: 3.6; CP: 3.5mL), recommencement of oral intake (AiFS: 1.3; CP: 1.4days), and postoperative hospitalization (AiFS: 4.3; CP: 3.8days) were not. CONCLUSION Because IPP was significantly lower during LA with AiFS, EtCO2 and BP were significantly lower. LEVEL OF EVIDENCE Treatment study; prospective comparative study - level II.

The value of mechanical bowel preparation prior to pediatric colorectal surgery: a systematic review and meta-analysis

PurposeThe use of mechanical bowel preparation (MBP) before pediatric colorectal surgery remains the standard of care for many pediatric surgeons, though the value of MBP remains unclear. The aim of this study was to systematically review and analyze the effect of MBP on the incidence of postoperative complications; anastomotic leakage, intra-abdominal infection, and wound infection, following colorectal surgery in pediatric patients.MethodsEmbase, MEDLINE, Web of Science, and CINAHL databases were searched to compare the effect of MBP versus no MBP prior to elective pediatric colorectal surgery on postoperative complications. After critical appraisal of included studies, meta-analyses were conducted using a random-effect model.Results1731 papers were retrieved; 2 randomized controlled trials and 4 retrospective cohort studies met the inclusion criteria. The overall quality of evidence was low. MBP before colorectal surgery did not significantly decrease the occurrence of anastomotic leakage, intra-abdominal infection, or wound infection compared to no MBP.ConclusionsOn the basis of the existing evidence, the use of MBP before colorectal surgery in children seems not to decrease the incidence of postoperative complications compared to no MBP. To overcome confounding factors such as antibiotic prophylaxis, age and type of operation, a multicentre prospective study is suggested to validate these results.

Initiation of Enteral Feeding After Necrotizing Enterocolitis

Abstract Introduction Management of necrotizing enterocolitis (NEC) consists of cessation of enteral feeding, intravenous antibiotic administration, and supportive treatment. There is no evidence‐based recommendation regarding when to restart feeding after a NEC episode. We performed a systematic review and meta‐analysis to examine the effect of timing of enteral feeding reinitiation on NEC recurrence. Methods MEDLINE, Embase, Google scholar, and Cochrane databases were searched. Human studies evaluating enteral feeding timing with a primary outcome of NEC recurrence were included. A total of 2,257 titles or abstracts were screened, and 47 full‐text articles were analyzed. A systematic review and meta‐analysis comparing NEC recurrence and other associated outcomes between early (<5 days after NEC diagnosis) and delayed (>5 days) initiation of enteral feeding after NEC were performed according to the PRISMA statement. The meta‐analysis data were analyzed using RevMan 5.3 to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Results Two retrospective observational studies met the inclusion criteria, comprising 56 cases in which enteral feeding was started early and 35 cases of delayed enteral feeding initiation. There were no randomized controlled trials (RCTs). The recurrence rates of NEC were unchanged between early (5.4%) and delayed (8.6%) enteral feeding groups (pooled OR = 0.61; 95% CI: 0.12‐3.16; p = 0.56; I2 = 0%). Catheter‐related sepsis (pooled OR = 0.20; 95% CI: 0.01‐3.29; p = 0.26; I2 = 67%) and post‐NEC stricture (pooled OR = 0.28; 95% CI: 0.07‐1.18; p = 0.08; I2 = 23%) rates were not different between early and delayed enteral feeding groups. Conclusion Initiating early enteral feeding, within 5 days of NEC diagnosis, is not associated with adverse outcomes, including NEC recurrence. In addition, catheter‐related sepsis and post‐NEC stricture rates were unchanged between early and delayed enteral feeding groups after NEC. However, the quality of the evidence from the review of literature is suboptimal. A further RCT is needed to confirm these results.