Suspension sutures facilitate single-incision laparoscopic-assisted rectal pull-through for Hirschsprung disease.

BACKGROUND: To present a surgical technique of single-incision laparoscopic-assisted endorectal pull-through (SILEP) with suspension sutures using conventional instruments for Hirschsprung disease (HD) and its long-term follow-up outcomes. METHODS: The procedure began with a 1 cm transumbilical skin incision. Three separate punctures were made in the fascia with a 5 mm scope in the middle and 5 mm and 3 mm ports for working instruments on the left and right, respectively. The first suspension suture was placed to secure the sigmoid colon to the abdominal wall. A window was created through the rectal mesentery, and dissection around the rectum was carried out. The second suspension suture was performed to suspend the rectovesical peritoneal fold or the rectovaginal peritoneal fold to the abdominal wall. Dissection around the rectum was continued downward to approximately 1 cm below the peritoneal fold. Then, the operation was completed by a transanal approach. RESULTS: Forty patients underwent SILEP from March 2013 to April 2015. The median age was 2.7 months (ranging from 1 to 17 months). The mean operative time was 96 ± 23 min. No conversion to an open operation was required. The average hospitalization time was 4.5 ± 2 days. There were no intraoperative or perioperative complications. Long-term follow-up results were obtained from 38 patients. A frequency of defecation from every other day to twice a day was noted for 33 patients (86.8%) and more often for 5 patients (13.2%). Two patients had enterocolitis (5.2%). CONCLUSION: Single-incision laparoscopic rectal pull-through with suspension sutures using conventional instruments is feasible and safe for HD with good long-term outcomes.

Granulocyte-colony stimulating factor GCSF mobilizes hematopoietic stem cells in Kasai patients with biliary atresia in a phase 1 study and improves short term outcome.

AIMS: In RCT of adults with decompensated cirrhosis, GCSF mobilizes hematopoietic stem cells HSC and improves short-term outcome. An FDA-IND for sequential Kasai-GCSF treatment in biliary atresia BA was approved. This phase 1 study examines GCSF safety in Kasai subjects. Preliminary short-term outcome was evaluated. METHODS: GCSF (Neupogen) at 5 or 10 µg/kg (n = 3/group) was given in 3 daily doses starting on day 3 of Kasai surgery (NCT03395028). Serum CD34+ HSC cell counts, and 1-month of GCSF-related adverse events were monitored. The 6-months Phase 1 clinical outcome was compared against 10 subsequent post Phase 1 Kasai patients who did not receive GCSF. RESULTS: With GCSF, WBC and platelet count transiently increased, LFT and serum creatinine remained stable. Reversible splenic enlargement (by 8.5-20%) occurred in 5/6 subjects. HSC count increased 12-fold and 17.5-fold for the 5 µg/kg and10 ug/kg dose respectively; with respective median total bilirubin levels for GCSF vs no-GCSF groups of 55 vs 91 µM at 1 month, p = 0.05; 15 vs 37 µM at 3 months, p = 0.24); and the 6-months cholangitis frequency of 40% vs 90%, p = 0.077. CONCLUSIONS: GCSF safely mobilizes HSC in Kasai infants and may improve short-term biliary drainage and cholangitis. Phase 2 efficacy outcome of GCSF adjunct therapy for sequential Kasai and GCSF is pending.

Laparoscopic Ladd's procedure in neonates: A simple landmark detorsion technique.

BACKGROUND: The aim of this study was to assess the efficacy of our simple landmark technique for laparoscopic detorsion and the Ladd's procedure (lap-Ladd) for malrotation with midgut volvulus in neonates and to identify the risk factors for reoperation after the lap-Ladd. METHODS: We conducted a retrospective chart review of 42 patients after lap-Ladd for malrotation between April 2017 and June 2019. Information regarding patient status and intraoperative and postoperative data were analyzed. RESULTS: Thirty-one patients had volvulus (73.8 %), while 11 patients did not (26.2%). The median age and weight between the two groups at operation were 9 days (range, 3-28 days), 3.2 kg (range, 2-8 kg) and 6 days (range, 2-11), 2.9 kg (range, 2-3.8 kg), respectively. The operative time was significantly shorter in patients with volvulus compared to those without (60 vs 105 min, P = 0.002). Two cases were converted to open surgery because of ischemic changes of the total small intestine during surgery. Reoperation was required in two patients with volvulus (due to adhesive small bowel obstruction and recurrent volvulus). There was no significant predictive factor for reoperation after the lap-Ladd procedure. CONCLUSION: Our simple landmark lap-Ladd procedure demonstrated feasibility and good short-term outcomes in neonates with malrotation, regardless of the presence or absence of volvulus.

Follow-Up Outcomes of Laparoscopic-Assisted Anorectal Pull Through for Anorectal Malformations of High Type.

Background: Laparoscopic-assisted endorectal pull-through (LAEPT) procedure in the management of high-type anorectal malformations (ARMs) was first introduced in 1998 and is quickly accepted worldwide. However, evidence on long-term outcomes of this technique is constrained. This study aims to evaluate the long-term outcomes of LAEPT for high-type ARMs in Vietnamese pediatrics. Materials and Methods: A longitudinal study was carried out from January 2009 to July 2014 in 56 patients <3 years old. Variables included age of operation, associated anomalies, type of fistula, the duration of hospital stay, complications, and long-term functional outcomes (Krickenbeck modified standards were used for children ≥3 years). Results: There were 56 patients including 48 males and 8 females. The mean age at operation was 3.7 months, the mean hospital stay was 4.6 days. The mean operative time was 76.7 minutes. The mean follow-up time was from 38 to 104 months (mean follow-up: 71.5 months). There were 46 (82.1%) patients having feeling of urge, 42 (75.0%) patients having capacity to verbalize, and 40 (71.4%) patients having hold the bowel movement. Conclusion: LAEPT is feasible, safe, and effective in the management of high-type ARMs.

Robotic-assisted surgery for choledochal cyst in children: early experience at Vietnam National Children's Hospital.

PURPOSE: We aimed to describe our robotic-assisted surgery (RAS) techniques and assess the early results of RAS for choledochal cysts in children. METHODS: We conducted a retrospective chart review of children who underwent RAS for a congenital choledochal cyst at our institution between February 2013 and August 2016. We analyzed patient characteristics, operative data, and postoperative outcomes. RESULTS: Thirty-nine patients underwent RAS for a choledochal cyst (female 30). The operation was performed with four robotic ports and one laparoscopic port for the assistant. The Roux loop was fashioned extracorporeally. Twenty patients (51.3%) had a Todani Type I cyst and the others had Type IV. The mean patient age and weight and choledochal cyst diameter at the time of the operation were 40.2 months (range 5-108 months), 13.4 kg (range 6.5-29 kg), and 27.2 mm (range 9-112 mm), respectively. The mean operating time was 192.7 min (range 150-330 min). There were no intraoperative complications; no conversions to laparoscopic or open surgery; and no postoperative complications, including cholangitis, cholelithiasis, or anastomotic stenosis. CONCLUSION: Pediatric RAS CC resection is safe and feasible. The robot-assisted technique overcame technical difficulties. However, in pediatric cases, a skilled robotic surgical team and procedural modifications are needed.

Early and intermediate outcomes of laparoscopic surgery for choledochal cysts with 400 patients.

OBJECTIVE: The aim of this study is to report early and intermediate outcomes of laparoscopic surgery for choledochal cysts with 400 cases. PATIENTS AND METHODS: The operation was performed using four ports. The cystic duct was identified and divided. The liver was suspended by two stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and biliary-digestive continuity was reestablished by hepaticoduodenostomy (HD) or hepaticojejunostomy (HJ). RESULTS: From January 2007 to June 2011, 400 patients were operated on. There were 305 girls and 95 boys. Ages ranged from 1 month to 16 years (mean, 47.5±2.1 months). Cystic excision and HD were performed in 238 patients and HJ in 162 patients. The mean operating time was 164.8±51 minutes for the HD group and 220±60 minutes for the HJ group. Conversion to open surgery was required in 2 patients. There were no perioperative deaths. Postoperative biliary leakage occurred in 8 patients (2%), resolving spontaneously in 7 and requiring a second operation in 1 patient. The mean postoperative hospital stay was 6.4±0.3 days for the HD group and 6.7±0.5 days for the HJ group. Follow-up between 5 months and 57 months postdischarge (mean, 24.2±2.7 months) was obtained in 342 patients (85.5%). Cholangitis occurred in 5 patients (1.5%) in the HD group and 1 patient (0.6%) in the HJ group. Gastritis due to bilious reflux was 3.8% in the HD group. CONCLUSIONS: Laparoscopic repair is a safe and effective procedure for choledochal cyst. The rate of cholangitis and anastomotic stenosis is low.