Robotic-assisted proctosigmoidectomy for Hirschsprung's disease: A multicenter prospective study.

BACKGROUND: Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung's disease (HSCR). AIM: To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients. METHODS: From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed. RESULTS: No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo. CONCLUSION: RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.

Differentiation between cystic biliary atresia and choledochal cyst: A retrospective analysis.

AIM: Cystic biliary atresia (CBA) can be easily misdiagnosed as choledochal cyst (CC). Some patients have already progressed to severe liver fibrosis and missed the optimal surgical time, when the differential diagnosis is made. We aim to determine the differentiation between CBA and CC, and to validate the value of aspartate aminotransferase-to-platelet ratio index (APRI) in the assessment of liver fibrosis and prediction of post-operative outcome for infants with biliary cystic malformations (BCMs). METHODS: Clinical data of children (categorised into CBA and CC groups) with BCMs were analysed retrospectively. Biochemical indicators together with B-ultrasound examinations and the degree of liver fibrosis were analysed, and those with statistical difference between the two groups were selected for diagnostic receiver operating characteristic curve analysis. RESULTS: The parameter that showed the highest accuracy with a significant diagnostic performance for differentiating CBA from CC was cyst size. Liver assessment at operation was categorised into mild fibrosis and moderate-to-severe fibrosis. The APRI values were much lower in the mild fibrosis groups than in the moderate-to-severe fibrosis group (0.4 ± 0.2 vs. 1.4 ± 0.8, P < 0.001). A cut-off value of 0.96 (area under the curve 0.92, P < 0.001) showed a sensitivity of 81.3% and a specificity of 100% for moderate-to-severe fibrosis. Lower APRI value was correlated with short-term post-operative bilirubin clearance. CONCLUSION: There is still certain difficulty in the early identification of CBA and CC clinically. Liver fibrosis could occur as early as infantile period in both CBA and CC. In infants with BCMs, APRI can be used as a non-invasive method to detect liver fibrosis in early stages.

[Surgical management of pyloric stenosis induced by gastrointestinal chemical burn in children].

OBJECTIVE: To investigate the efficacy of surgical management for pyloric stenosis induced by gastrointestinal chemical burn in children. METHODS: Clinical data of 11 children with pyloric stenosis induced by gastrointestinal chemical burn were analyzed retrospectively. After the failure of medicine, intervention of low balloon expansion and stent placement, they underwent pylorectomy and gastroduodenostomy. The body weight, height, serum albumin, hemoglobin, transferrin were compared between 1 day before and 3 months after operation. RESULTS: There were 10 males and 1 female with a mean age of 4.5 years old. The main cause of serious pyloric stenosis was the wrong intake of hydrochloric acid. Lesions involved the esophagus and stomach in the early stage, and 4 weeks later, the lesion mainly involved the pylorus, which resulted in scarring pyloric stenosis and complete pyloric obstruction. Pylorectomy and gastroduodenostomy was successfully performed. The mean operative time was (134±26) min. The estimated blood loss was (5±2) ml. The postoperative length of stay was (10±3) d. There were no surgical complications. During the follow-up of 3 months, all the patients resumed regular diet. The height, body weight, and intelligence appeared to be normal. They showed significant improvement in weight, serum albumin, globulin, hemoglobin, transferrin at 3 months after the surgery(P<0.05). Six months after surgery, the anastomosis was shown to be nornal in barium follow through exam with no signs of stricture of ulcer. CONCLUSION: Pylorectomy and gastroduodenostomy is an effective management for pyloric stenosis induced by gastrointestinal chemical burn in children, whose short-term efficacy is good.

[Early-stage bacterial infection following orthotopic liver transplantation in patients over 60 years old].

OBJECTIVE: To summarize the pathogenic characteristics of bacterial infection and analyze the risk factors after orthotopic liver transplantation (OLT) in patients over 60 years of age. METHODS: A retrospective study of 69 patients that were over 60 years of age and underwent OLT was carried out. Descriptive statistics and risk factor analysis were performed with SPSS 11.0. RESULTS: Thirty-eight patients developed bacterial infection (55.1%) after OLT, and thirty recipients suffered from mixed bacterial infection (79.0%). Multi-location infection was most commonly seen (68.4%). Nine patients died of bacterial infection. The primary pathogenic germs included enterococcus, methicillin-resistant coagulase negative staphylococcus, c maltophilia. The risk factors related to bacterial infection included preoperative malnutrition, long anhepatic phase, use of ventilator and duration of ICU stay. CONCLUSIONS: The old patients that have undergone OLT are susceptible to bacterial infection. Bacterial infections are associated with high rate of mortality and multidrug resistance. Eliminating various risk factors can reduce the incidence of bacterial infection.

[Orthotopic liver transplantation in patients over 60 years old].

OBJECTIVE: To investigate the outcome and relative problems of patients over 60 years old underwent orthotopic liver transplantation (OLT). METHODS: Data of patients over 60 years old (>or= 60 years old group, n = 59) patients recipients who were 18 to 59 years old (< 60 years old group, n = 500) were reviewed retrospectively. RESULTS: Overall patients survival at 1 year was not significantly different among >or= 60 years old group (66%) and < 60 years group (76%). There were no differences in the operation time, the quantity of blood lost during operation, the days of hospitalization and the incidence of hepatic artery thrombosis between the two groups. The incidence rate of acute rejection reaction in >or= 60 years old group was lower. Both the duration of staying in intensive care unit and the time of using ventilator in >or= 60 years old group were longer than the other group. Moreover, the incidence rates of infection and intracerebral hemorrhage were higher in >or= 60 years old group, which were the primary causes of death in this group. CONCLUSION: Even though the complications were higher, recipients over 60 years old underwent OLT have more excellent 1 year survival.

[Combined total hepatectomy, orthotopic liver transplantation and pancreatoduodenectomy for unresectable hilar bile duct carcinoma].

OBJECTIVE: To explore the feasibility and outcome of combined hepatectomy, orthotopic liver transplantation and Whipple's pancreatoduodenectomy for radical excision of cholangiocarcinoma. METHODS: A 35-year-old female patient with unresectable cholangiocarcinoma underwent curative radical operation, which includes hepatectomy, orthotopic liver transplantation and pancreaticoduodenectomy of hilar bile duct carcinoma; immunosuppression followed an induction protocol with FK506 and steroids. Lamivudine and HBIg were used to prevent hepatitis B virus from infection again. RESULTS: Pathologic examination revealed low differentiated cholangiocarcinoma and immunohistochemistry stains demonstrated positive expression of cytokeratin 9 and 17, carcinoembryonic antigen and the hepatocyte protein was negative. Neither the margins of resection nor the periductal lymph nodes were involved. The liver showed evidence of cholestasis and metastasis nod. The patient was hospitalized 32 days and came back to the previous work. He has been followed up for more than 14 months up to now and is currently alive without any evidence of recurrent cancer. CONCLUSIONS: For some selected unresectable Klatskin's tumors, combined hepatectomy, pancreatoduodenectomy and orthotopic liver transplantation was justified. The radical methods maybe provide long-time survival and curative effect. Nevertheless, because of possible tumor recurrence and ethical controversy, the combined hepatectomy, pancreatoduodenectomy and orthotopic liver transplantation procedure has to be applied only with caution and indications.