T-tube enterostomy in the management of apple-peel atresia: A case series from a single center.

Background and objective: Although complex atresias, such as apple-peel and multiple atresias, comprise a smaller percentage, they are usually associated with a higher incidence of postoperative complications and mortality rate. Contrary to simple atresias where the surgical technique of choice usually entails bowel resection and anastomosis with or without enteroplasty, managing apple-peel atresia remains more sophisticated. Decompressive and functionalizing stomas are sometimes mandatory to overcome problems such as increased wall thickness and the wide disparity among the anastomotic ends. Few reports discussed using tube enterostomy in the management of apple-peel atresia; nonetheless, no previous prospective studies were conducted to discuss its efficacy on a larger population. In this study, we are describing our experience using this technique on 12 patients suffering from apple-peel atresia in our center. Methods: A prospective study was conducted from June 2015 to May 2020, where all children who were found to have apple-peel atresia were included in the study. T-tube was placed through an enterotomy through the dilated proximal bowel, around 10 cm before the anastomotic line, and was kept in place using a double suture (Stamm technique) before closing the anterior face of the anastomosis. The short distal limb of the T-tube was oriented toward the anastomotic line, while the long proximal limb was directed proximally. After finishing the anastomosis, the T-tube was delivered outside the abdominal wall, anchoring the enterostomy along with the proximal dilated jejunum against the anterior abdominal wall. Results: A total of 12 cases were encountered throughout the period of study. The mean age at operation was 4 days and the mean birth weight was 2700 g. The mean time for starting oral feeding postoperatively and T-tube removal was 8 and 10.5 days, respectively. Cases were discharged after a mean of 22 days. As regards morbidity and mortality, a single case developed skin excoriations at the site of tube insertion and was managed conservatively using topical ointments and another case died from overwhelming sepsis 3 days after the operation. Conclusion: T-tube enteroplasty is a safe and feasible option in the surgical management of apple-peel atresia. The main strength of our study is its prospective nature and that it includes apple-peel atresia cases only. However, the main limitation is that a larger sample is needed.

A new approach to laparoscopic appendectomy in children-clipless/sutureless Harmonic scalpel laparoscopic appendectomy.

BACKGROUND: The aim of this study was to investigate Harmonic scalpel performance in laparoscopic appendectomy for sealing the base of the appendix in children. METHODS: During the study period, a total of 312 patients who underwent laparoscopic appendectomy were included in prospective bicenter clinical trial. The patients were divided in two study groups in regard to technique used for appendiceal base closure. In the first group (n = 197) the appendiceal base was secured using a polymeric clip while in the second group (n = 115) the Harmonic scalpel was used for sealing the base in a stepwise manner, without placing any clip or suture. Outcomes of treatment, including complication rates, duration of surgery and length of hospital stay were compared between the groups. RESULTS: A total of 312 patients with a median age of 11 years (IQR 8, 15) were included in study. Of these, 191 were males (61.2%). Both groups were symmetric in regard to baseline characteristics of the patients. A total of 10 (5.1%) postoperative complications (postoperative abscess n = 7 and ileus n = 3) were recorded in the polymeric clip group while none of the patients from the clipless group had postoperative complications (P = 0.015). In the group who received a polymeric clip appendectomy, fever lasting 0-72 h and > 72 h was recorded in 16 (8.1%) and 12 (6.1%) children, respectively, while in the clipless group, it was observed in 2 (1.7%) and 5 (4.3%) children, respectively (P = 0.048). Significantly shorter surgical times were found in the clipless group compared to the polymeric clip group (21 min (IQR 18, 25) vs. 30 min (IQR 22, 40), P < 0.0001). Also, length of hospital stay was significantly shorter in the clipless group of the patients (2 days (IQR 2, 3) vs. 3 days (IQR 2, 4), P < 0.0001). CONCLUSION: Clipless harmonic scalpel laparoscopic appendectomy is a safe and effective method in children for treatment of acute appendicitis with lesser number of complications and shorter duration of surgery compared to laparoscopic appendectomy in which the appendiceal base is secured with clip.

Intussusception in preterm neonates: A systematic review of a rare condition.

BACKGROUND: While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis METHODS: A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study. RESULTS: Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel's diverticulum. Nine cases only out of the 52 cases with IPN died. CONCLUSION: It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.

Neonatal Gastrointestinal Stromal Tumor of the Sigmoid Colon: A Case Report and Review of Literature.

ABSTACTBackground: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the digestive tract. They are believed to originate from the interstitial cells of Cajal or their precursors. Case Report: A 10-day-old boy presented with intestinal obstruction. He was operated upon and a mass was found at the sigmoid colon, which was resected and divided colostomy was performed. The diagnosis of neonatal GIST was confirmed by histologic and immunohistochemical studies. Conclusion: This is the ninth case of neonatal GIST that arose from the intestine and the first reported to arise from the sigmoid colon. Colonic GIST can occur in the neonatal age group.