Intestinal perfusion assessed by quantitative fluorescence angiography in piglets with necrotizing enterocolitis.

BACKGROUND: Reduced intestinal perfusion is thought to be a part of the pathogenesis in necrotizing enterocolitis (NEC). This study aims to evaluate the intestinal perfusion assessment in NEC-lesions by quantitative fluorescence angiography with indocyanine green (q-ICG) during laparoscopy and open surgery. METHODS: Thirty-four premature piglets were delivered by cesarean section and fed with parenteral nutrition and increasing infant formula volumes to induce NEC. During surgery, macroscopic NEC-lesions were evaluated using a validated macroscopic scoring system (1-6 for increasing NEC severity). The intestinal perfusion was assessed by q-ICG and quantified with a validated pixel intensity computer algorithm. RESULTS: Significantly higher perfusion values were found in healthy areas of the colon (score 1) compared to those with NEC scores of 4, 5, and 6 (p < 0.05). Similarly, in the small intestine, perfusion was higher in the intestine with areas scored 1 compared to scores of 3 and 4 (p < 0.05). A cut-off value was found between NEC score of 1-2 vs. 3-4 for the small intestine at 117 and for colon at 107 between NEC scores 12 vs. scores of 36 with an area less than the curve value at 0.9 (p < 0.05). CONCLUSIONS: q-ICG seems to be a feasible and valuable technique to evaluate the perfusion of tissue with NEC-lesions. We found a cut-off between intestine with scores 1-2 and intestine with NEC scores 3-6 in colon, and NEC score 3-4 in the small intestine. LEVEL OF EVIDENCE: II.

Sigmoid volvulus in children.

Sigmoid volvulus in paediatric patients is a rare but potentially life-threatening condition. Since 1940, only 100 cases have been reported. There are no consensual guidelines for juvenile sigmoid volvulus unlike in adults, where the condition and the treatment is well described. We report a case of a 12-year-old patient, who presented with uncharacteristic symptoms of mild abdominal discomfort and lack of passage of stool. A CT-scan showed a sigmoid volvulus and emergency resection was performed with placement of a colostomy. With this case, we want to emphasise juvenile sigmoid volvulus as a probable differential diagnosis when symptoms of abdominal distress and constipation occur.

Early diagnosis and treatment for intussusception in children is mandatory.

INTRODUCTION: In some cases, surgical treatment is necessary to manage intussusception despite advances in enema reduction. The purpose of this study was to analyse treatment in two tertiary referral university centres for paediatric surgery to identify time-related factors influencing treatment of intussusception. METHODS: This was a retrospective two-centre chart review, performed for all patients under the age of 16 years who underwent treatment for intussusception during the period from 2005 to 2015. Demographic data and data on different time intervals from symptom debut to end of treatment and compliacations were retrieved from the medical record. RESULTS: A total of 158 children were included. Non-surgical reduction was used as the primary treatment modality in 48% and intussusception was successfully reduced in 32% of these cases. The non-surgical success rate was found to be significantly higher when the diagnosis was confirmed within four hours of hospitalisation (p = 0.003). A lower rate of bowel resection was observed when the diagnosis was confirmed within four hours of hospitalisation (p = 0.026) and treatment was initiated within six hours of hospitalisation (p = 0.033). CONCLUSIONS: This study found a relatively low utilisation rate for enema reduction and an overall low enema success rate. The success rate of enema was significantly higher and the intestinal resection rate lower when the diagnosis was confirmed within four hours of hospitalisation, which underpins the importance of a quick and timely diagnosis. FUNDING: none. TRIAL REGISTRATION: not relevant.

Bovine Milk-Derived Emulsifiers Increase Triglyceride Absorption in Newborn Formula-Fed Pigs.

Efficient lipid digestion in formula-fed infants is required to ensure the availability of fatty acids for normal organ development. Previous studies suggest that the efficiency of lipid digestion may depend on whether lipids are emulsified with soy lecithin or fractions derived from bovine milk. This study, therefore, aimed to determine whether emulsification with bovine milk-derived emulsifiers or soy lecithin (SL) influenced lipid digestion in vitro and in vivo. Lipid digestibility was determined in vitro in oil-in-water emulsions using four different milk-derived emulsifiers or SL, and the ultrastructural appearance of the emulsions was assessed using electron microscopy. Subsequently, selected emulsions were added to a base diet and fed to preterm neonatal piglets. Initially, preterm pigs equipped with an ileostomy were fed experimental formulas for seven days and stoma output was collected quantitatively. Next, lipid absorption kinetics was studied in preterm pigs given pure emulsions. Finally, complete formulas with different emulsions were fed for four days, and the post-bolus plasma triglyceride level was determined. Milk-derived emulsifiers (containing protein and phospholipids from milk fat globule membranes and extracellular vesicles) showed increased effects on fat digestion compared to SL in an in vitro digestion model. Further, milk-derived emulsifiers significantly increased the digestion of triglyceride in the preterm piglet model compared with SL. Ultra-structural images indicated a more regular and smooth surface of fat droplets emulsified with milk-derived emulsifiers relative to SL. We conclude that, relative to SL, milk-derived emulsifiers lead to a different surface ultrastructure on the lipid droplets, and increase lipid digestion.

Complicated Meckel's Diverticulum in Children: Clinical Presentation, Diagnostic Work-Out, Surgical Approach and Postoperative Complications.

Introduction Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. The majority of cases are asymptomatic and in cases with complications, the diagnosis may be a challenge and the surgical approach is not obvious. The primary aim of the present study was to evaluate the diagnostic process and surgical approach in relation to clinical presentation. The secondary aim was to evaluate the severity of postoperative complications.  Methods A two-center, retrospective analysis of all children below the age of 15 years, operated for complications to MD during the period from January 2003 to December 2016. Results A total of 58 patients were included. In the 40 patients presenting with an acute abdomen an average of 2.3 preoperative diagnostic investigations was performed. In only five cases an MD was recognized preoperatively. In the 18 patients presenting with rectal bleeding or melaena an average of 3.2 preoperative investigations were performed and in only one case the MD was recognized preoperatively. Laparoscopy was the surgical approach in 36 patients (62%) with a conversion in 8. Postoperative complications were seen in two patients (Clavien-Dindo II and IIIb). Conclusion Despite extensive diagnostic work-out an MD was recognized in only a few patients preoperatively. Laparoscopy was the surgical approach in two-thirds of the patients.

Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates.

Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.

Reproducibility and Reliability of Repeated Quantitative Fluorescence Angiography.

INTRODUCTION: When using fluorescence angiography (FA) in perioperative perfusion assessment, repeated measures with re-injections of fluorescent dye (ICG) may be required. However, repeated injections may cause saturation of dye in the tissue, exceeding the limit of fluorescence intensity that the camera can detect. As the emission of fluorescence is dependent of the excitatory light intensity, reduction of this may solve the problem. The aim of the present study was to investigate the reproducibility and reliability of repeated quantitative FA during a reduction of excitatory light.

Laser Speckle Contrast Imaging to Evaluate Bowel Lesions in Neonates with NEC.

Background Necrotizing enterocolitis (NEC) is the most frequent surgical emergency in newborns. Intestinal ischemia is considered a factor that precedes the development of NEC lesions. Laser speckle contrast imaging (LSCI) can be used to assess tissue microcirculation. We evaluated if LSCI may help to detect intestinal regions with reduced microcirculation in NEC. Case Report A male patient (gestational age, 26 [3/7] weeks; birth weight, 600 g) showed clinical signs of NEC 28 days after birth. X-ray revealed pneumatosis intestinalis and portal gas. Laparotomy showed NEC lesions with signs of transmural ischemia in the terminal ileum and cecum. Surgical resection lines (RLs) were marked, followed by LSCI measurements and resection of the bowel between the two RLs. Post hoc LSCI analyses were conducted on both sides of the proximal and distal RL. Low-flux values, indicating reduced microcirculation, were found in the macroscopically assessed necrotic bowel at the proximal RL, whereas higher flux values, indicating sufficient microcirculation, were found in the macroscopically assessed normal bowel. Discussion This study is the first description of intra-abdominal use of LSCI to evaluate tissue microcirculation in relation to NEC lesions. LSCI could be a valuable tool to distinguish between ischemic and nonischemic bowel in neonates undergoing surgery for NEC.

Robotic surgery start-up with a fellow as the console surgeon.

OBJECTIVE: Owing to the encouraging data on fellowship training in robotic pyeloplasty and the documented benefits of robotic pyeloplasty, the aim of this study was to test the feasibility of starting up pediatric urological robotic surgery in a center with a limited case volume. MATERIALS AND METHODS: The operative parameters and clinical outcome of the first 25 robotic pyeloplasties performed were compared to data on open and laparoscopic procedures from the previous 5 year period. The fellow was the only console surgeon. An experienced non-robotic pediatric urologist was supervising at the patient site. RESULTS: The learning curve was in accordance with previously published data on fellows. The median operating time in robotic surgery was 182 min and was significantly shorter than in laparoscopic surgery (median 250 min) and the postoperative inpatient length of stay was significantly shorter after robotic surgery (median 1 day) than after both laparoscopic (median 2 days) and open surgery (median 3.5 days). For robotic cases, postoperative renography showed either stable or increased function of the hydronephrotic kidney. The only complication was in one case with ureteral orifice edema after JJ-stent removal, requiring nephrostomy for 6 weeks. CONCLUSIONS: The benefits of overall shorter postoperative hospital stay after robotic pyeloplasty and faster operating time compared to the laparoscopic procedure are clearly in accordance with data from the recent literature. The fast learning curve for robotic pyeloplasty will allow pediatric urology fellowship programs to be integrated in the start-up phase of a pediatric robotic program even though the case material is limited. Operative success rates were in accordance with the gold standard of open surgery.

[Evaluation and treatment of patients after caustic ingestion].

This article presents recommendations regarding early management of patients after intake of corrosive chemicals, based on best evidence and clinical experience. Risk assessment built on clinical history, presentation and endoscopy is discussed as well as initial treatment, surgical appraisal and observation. Controversy still surrounds the need for endoscopy in asymptomatic patients, the use of computed tomography in assessing the severity of lesions as well as pharmacological treatment for preventing strictures.

[Bleeding oesophageal varices in a seven-year-old boy supposedly as a late complication to neonatal umbilical venous catheter].

A seven-year-old boy was admitted with haematemesis. The boy was originally born at 27 weeks' gestational age. His neonatal period had been complicated by sepsis, for which he was treated with antibiotics through an umbilical venous catheter (UVC). A gastroscopy showed grade III oesophageal varices with bleeding. He was examined thoroughly for other causes of portal hypertension, but none were found. Portal hypertension caused by UVC in the neonatal period is a rare but very serious complication to neonatal UVC.

Bovine colostrum to children with short bowel syndrome: a randomized, double-blind, crossover pilot study.

BACKGROUND: Management of short bowel syndrome (SBS) aims to achieve intestinal autonomy to prevent fluid, electrolyte, and nutrient deficiencies and maintain adequate development. Remnant intestinal adaptation is required to obtain autonomy. In the newborn pig, colostrum has been shown to support intestinal development and hence adaptive processes. AIM: The efficacy of bovine colostrum to improve intestinal function in children with SBS was evaluated by metabolic balance studies. MATERIALS AND METHODS: Nine children with SBS were included in a randomized, double-blind, crossover study. Twenty percent of enteral fluid intake was replaced with bovine colostrum or a mixed milk diet for 4 weeks, separated by a 4-week washout period. Intestinal absorption of energy and wet weight was used to assess intestinal function and the efficacy of colostrum. RESULTS: Colostrum did not improve energy or wet weight absorption compared with the mixed milk diet (P = 1.00 and P = .93, respectively). Growth as measured by weight and knemometry did not differ between diets (P = .93 and P = .28). In these patients, <150% enteral energy absorption of basal metabolic rate and 50% enteral fluid absorption of basal fluid requirement suggested intestinal failure and a need for parenteral nutrition (PN). CONCLUSION: Inclusion of bovine colostrum to the diet did not improve intestinal function. Metabolic nutrient and wet weight balance studies successfully assessed intestinal function, and this method may distinguish between intestinal insufficiency (non-PN-dependent) and intestinal failure (PN-dependent) patients.

Complication rate after circumcision in a paediatric surgical setting should not be neglected.

INTRODUCTION: As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated our results from a paediatric surgical department. MATERIAL AND METHODS: Patient file data from children who had undergone ritual circumcision in the 1996-2003 period were retrieved. Complications recorded until December 2011 were noted. RESULTS: Circumcision in 315 boys aged from 3 weeks to 16 years (median five years) were evaluated. A total of 16 boys (5.1%) had significant complications, including three incomplete circumcisions requiring re-surgery, two requiring re-surgery six months and five years postoperatively due to fibrotic phimosis and two requiring meatotomy due to meatal stenosis two and three year postoperatively. Acute complications included two superficial skin infections one week postoperatively and five cases with prolonged stay or re-admissions for bleeding the first or second postoperative day, whereof two underwent operative treatment. Finally, two had anaesthesiological complications leading to a need for overnight surveillance, but no further treatment. DISCUSSION: Parents should be counselled and be required to provide informed consent that any health benefits of childhood circumcision do not outweigh the reported complication rate and that therefore they should weigh the health benefits against the risks in light of their religious, cultural and personal preferences. As ritual circumcision is legal, a strong focus on high surgical/anaesthesiological standards is needed to avoid complications. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Colonoscopy results are not enhanced by use of magnet endoguide in specialist practice.

INTRODUCTION: It is discussed whether the use of a magnetic positioning device (OLYMPUS; UPD (unit of magnetic positioning device)) enhances the success of the colonoscopic procedure. Concern for patient compliance and endoscopic efficiency has been voiced in connection with the implementation of colon cancer screening. UPD has been proposed as a tool for optimization of results and reduction of patient discomfort. In this study, we aimed to qualify the debate by examining the success rate and patient discomfort in an unselected colonoscopy population referred to specialist clinics with experienced investigators. Furthermore, the study assessed the effect of using a UPD. MATERIAL AND METHODS: A total of 1,068 consecutive patients referred for colonoscopy were enrolled and randomised for investigation with or without use of UPD. The evaluation endpoints were: success rate (coecum visualised, ileal intubation was carried out at the investigator's discretion), duration of procedure, and patient discomfort indicated by the patient as a visual analogue scale score. RESULTS: No significant differences between the two investigational procedures were demonstrated in relation to the chosen endpoints. CONCLUSION: UPD is convenient to have, but not a necessity for colonoscopy. FUNDING: The study was supported by the Danish Association of Medical Specialists. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency, journal no. 2009-41-3716, the National Ethics Committee, journal no.: H-1-2009-80, and registered with ClinicalTrials.gov., protocol no: NCT01055782.

[Pancreatic trauma in children--operative versus non-operative treatment]. / Pancreastraumer hos børn--operativ versus nonoperativ behandling.

Pancreatic trauma is more frequent in children than in adults and is often caused by trauma to the upper part of the abdomen. Mortality is low, but morbidity is high. Pancreatic trauma can be treated operatively or non-operatively, but there is disagreement about the optimal treatment strategy for patients with severe pancreatic lesions. In general, good results are achieved with non-operative treatment and secondary surgery is avoided, but prospective trials are needed to evaluate the method.