Case report: a case of multiple splenic abscesses in a child and literature review.

Splenic abscesses in children are very rare, and multiple splenic abscesses are rarer. These lesions are difficult to diagnose quickly because of their low incidence and the low specificity of the associated clinical and imaging findings. The treatment of splenic abscesses includes conservative treatment, percutaneous drainage, and splenectomy, but the selection criteria for treatment are still unclear. We present a case of a 13-year-old girl with multiple splenic abscesses. Her blood culture report was negative. We eventually confirmed the diagnosis by enhanced magnetic resonance imaging (MRI). The patient underwent a successful laparoscopic total splenectomy, and her symptoms were resolved thereafter.

Intraoperative hepatic subcapsular spider-like telangiectasia sign for the definitive diagnosis of biliary atresia.

OBJECTIVE: To evaluate the accuracy of intraoperative hepatic subcapsular spider-like telangiectasia (HSST) sign for differentiating biliary atresia (BA) from other causes of hepatic cholestasis. METHODS: The data of 69 patients with jaundice treated from January 2019 to December 2021 were retrospectively analyzed. Based on intraoperative cholangiography (IOC), the patients were divided into two groups: the BA group (n = 49) and the non-BA group (n = 20). The biochemistry tests, liver ultrasound, liver stiffness value and HSST sign of the two groups were compared. RESULTS: The incidence of abnormal gallbladder, elevated γ-glutamyl transpeptidase (γ-GGT) > 182.0U/L and abnormal liver stiffness (> 6.4 kPa) in BA group were significantly higher than those in non-BA group (P < 0.001). The HSST sign was present in all BA patients and not found in non-BA group. The area under receiver operating curve of direct bilirubin(DBIL), γ-GGT, abnormal gallbladder, liver stiffness value and HSST sign were 0.53, 0.84, 0.78, 0.96, and 1.00, respectively. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value(NPV) of HSST sign in the diagnosis of BA were all 100%. CONCLUSION: Presence of HSST sign on diagnostic laparoscopy is highly suggestive of BA.It can be used in the differential diagnosis of BA and non-BA. LEVEL OF EVIDENCE: Level III.

Value of gallbladder length-to-width ratio for diagnosis of biliary atresia by correlation with age.

The objective is to explore the correlation between ultrasonic gallbladder length-width ratio (LTWR) and age, and the value of differential diagnosis between biliary atresia (BA) and other hepatic cholestasis. From January 2016 to June 2022, the data of 183 patients with jaundice who underwent abdominal ultrasound and surgical exploration in the Affiliated Hospital of Zunyi Medical University were analyzed retrospectively. The demographic data, liver function, and ultrasonic parameters were recorded and analyzed. There were statistically significant differences between BA group and non-BA group in maximum length, maximum width and LTWR of gallbladder (P < 0.001). In all age groups (I: ≤ 30 days; II: 31-60 days; III: 61-90 days; IV: 91-120 days; V: ≥ 121 days), in which group III (61-90 days) had the highest area under the curve (AUC) of 0.843, and group V (≥121 days) had the lowest AUC of 0.548. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of gallbladder LTWR > 3.26 for BA in group II (31-60 days) were 78.9%, 75.0%, 75.0%, 78.9% and 76.9%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of gallbladder LTWR > 3.69 for BA in group III (61-90 days) were 76.6%, 84.6%, 92.5%, 59.5% and 78.9%, respectively. Ultrasonography LTWR of gallbladder has certain value in the diagnosis of BA. The diagnostic value of gallbladder LTWR in infants with different ages was quite different, and it was relatively high in infants with 31-90 days.

Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice?

Objective: Congenital diaphragmatic hernia (CDH) is an uncommon but potentially life-threatening surgical condition in neonates. Surgery can be performed by either open or thoracoscopic techniques. In this study, we compared the clinical efficacy, safety, and effectiveness of thoracoscopic and open CDH repair. Methods: A retrospective review of neonates with CDH who underwent operations at our hospital from 2013 to 2021 was performed. The various perioperative parameters were compared between neonates undergoing thoracoscopic and open surgery. Results: There were 50 neonates in this study (37 in the thoracoscopic group and 13 in the open group). Thoracoscopic surgery was associated with significantly shorter hospital stay (13.32 vs. 18.77 days, p < 0.001); shorter duration of postoperative mechanical ventilation (3.70 vs. 5.98 days, p < 0.001); early feeding (4.34 vs. 7.46 days, p < 0.001); and shorter time to reach optimal feeding (8.21 vs. 13.38 days, p < 0.001). There was one postoperative death in the open group and no death in the thoracoscopic group. The median follow-up time of the two groups was 23.8 months (20.5 months in open group and 25.0 months in thoracoscopic group). Thoracoscopic surgery was associated with lower recurrence rates, but the difference was not statistically significant (2.7% vs. 7.7%, p = 0.456). Conclusion: Thoracoscopy CDH repair, a safe and effective surgical technique for neonates, has better cosmesis, faster postoperative recovery, and a lower recurrence rate than other procedures. It can be considered the first choice for CDH treatment for neonates among experienced surgeons.

Case report: A case of giant accessory hepatic lobe torsion combined with left hepatic vein branch thrombosis in a child.

The accessory hepatic lobe (AHL) is a rare congenital malformation of the hepatic tissue, among which the giant AHL is the rarest in children. Patients without complications are usually asymptomatic, and most auxiliary examinations cannot provide a definitive preoperative diagnosis. Surgical procedure is the only recommended management for patients who suffered from the complications of AHL. We report the case of a rare pediatric giant AHL torsion combined with left hepatic vein branch thrombosis which was successfully treated by laparoscopic lobectomy followed by excision of AHL.

Relationship between the expression levels of CD4+ T cells, IL-6, IL-8 and IL-33 in the liver of biliary atresia and postoperative cholangitis, operative age and early jaundice clearance.

OBJECTIVE: To investigate the expression levels of CD4+ T cells, IL-6, IL-8 and IL-33 in liver tissue of BA, and the relationship with postoperative cholangitis, operative age and early jaundice clearance. METHODS: 45 cases of jaundice treated in the hospital from June 2018 to May 2020 were analyzed retrospectively. The expression and distribution of these factors were detected by HE staining and immunohistochemistry, the total bilirubin level and the incidence of cholangitis were recorded, and the relationship between liver inflammation level and the postoperative incidence of cholangitis, age of operation and early jaundice clearance were compared. RESULTS: Immunohistochemistry showed that the expression of CD4+ T cells, IL-6, IL-8 and IL-33 in the BA group were higher than those in the CBD group. ROC curve analysis showed the AUC of CD4+ T cells, IL-6 and IL-8 were 0.869, 0.886 and 0.838, respectively. The expression level of CD4+ T cells was negatively correlated with the decline rate of TBIL 3 months after operation, and the expressions of IL-8 and IL-33 were negatively correlated with the decline rate of TBIL 1 week after operation. CONCLUSION: The high expression of CD4+ T cells, IL-6, IL-8 and IL-33 in the BA liver tissue may lead to cholangitis and can be used as a predictor of early jaundice clearance. The degree of liver inflammation infiltration had nothing to do with the age of operation and is not a risk factor for postoperative cholangitis.

Comparative analysis of cystic biliary atresia and choledochal cysts.

Objective: Cystic biliary atresia (CBA) is a rare and peculiar type of biliary atresia (BA) that is easily confused with infantile choledochal cysts (CCs). This study explored information for early CBA diagnosis and treatment. Method: The authors retrospectively analyzed the clinical data of 32 children with hilar cysts from January 2013 to May 2021. According to the diagnosis, they were divided into the CBA (n = 12) and CC (n = 20) groups. Patient features, biochemical indexes, preoperative ultrasound characteristics, cholangiography features, and intraoperative findings were analyzed and compared between the two groups. Results: The alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin levels in the CBA group were higher than in the CCs group (P < 0.05). Additionally, B-mode ultrasound showed a cystic mass in front of the hepatic hilum, and the cyst size was much smaller in the CBA group compared with the CC group (2.2 ± 1.3 cm vs. 6.0 ± 2.2 cm, P < 0.001). Among all of the parameters, cyst width was the most accurate for identifying CBA and CCs. A cutoff value of 2.5 cm (area under the curve, 0.98, P < 0.001) showed 90.9% sensitivity and 95% specificity for cyst size. Conclusion: For children with early-onset severe jaundice, and if the width of the cystic mass was ≤2.5 cm, a diagnosis of CBA was highly likely. Early cholangiography and surgical treatment are necessary for the effective treatment of these infants.

Anesthesia Management of a Premature Neonate with Congenital Heart Disease during Emergency Diaphragmatic Hernia Surgery: A Case Report.

In this medical report, we successfully implemented anesthesia management for an infant with congenital heart disease undergoing congenital diaphragmatic hernia (CDH) repair. Left-sided CDH was diagnosed on a postnatal chest X-ray on day 1 of her life. The child was complicated with congenital heart diseases and pulmonary hypertension and showed severe dyspnea immediately after birth. Thoracoscopic CDH repair puts forward high requirements for anesthesia. Neonatal CDH combined with congenital heart disease brings more challenges to anesthesia. For high-risk premature neonates, anesthesia selections are essential, as those factors directly affect the prognosis. We report the application of S-ketamine as an anesthetic in this kind of operation for the first time. The postoperative recovery was uneventful. This case report reviews anesthesia management of critical CDH neonates, hoping to provide information to healthcare professionals unfamiliar with the treatment of this kind of patient.

Laparoscopic Complete Excision of the Posterior Muscular Cuff: Technique Refinements and Comparison With Stepwise Gradient Muscular Cuff Cutting for Hirschsprung Disease.

Objectives: Our institution had modified the Soave pull-through procedure using laparoscopic stepwise gradient muscular cuff cutting (LSGC) for Hirschsprung disease (HSCR). However, we found that a few children still suffered from obstructive symptoms and enterocolitis during the follow-up. Previous studies suggested that these symptoms might be caused by the retained muscular cuff. The purpose of this study was to employ a modified procedure of laparoscopic complete excision of the posterior muscular cuff (LCEPC) for HSCR and compare it with the laparoscopic stepwise gradient cutting muscular cuff (LSGC) procedure. Methods: Our institution records of 83 patients with classic form HSCR who underwent LSGC or LCEPC between August 2014 and July 2018 at the Pediatric Surgery Department of Zunyi Medical University (Zunyi, China) were carefully reviewed (LSGC, n = 52; LCEPC, n = 31). In the present study, we compared the postoperative complications and defecation functions of the two groups. All patients were followed-up (1-5 years, with an average of 2 years). Results: There were no differences regarding the operation time and the length of hospitalization between groups, while the anal dissection time in the LCEPC group (22.4 ± 4.8 min) was shorter than that of the LSGC group (45.5 ± 7.5 min) (p < 0.001). The postoperative complication of soiling was significantly increased in six patients (19.4%) in the LCEPC group compared with two patients (3.8%) in the LSGC group (p = 0.021). However, the total incidence of enterocolitis (two patients, 6.5%) was significantly decreased in the LCEPC group compared with the LSGC group (12 patients, 23.1 %) (p = 0.050). For anastomotic stricture, muscular cuff infection, and constipation, there were no significant differences between the two groups. No patients experienced bladder paralysis and incontinence postoperatively in this study. Anorectal manometries presented that the anorectal resting pressure was significantly lower in the LCEPC group (14.8 ± 2.7 mmHg) than the LSGC group (22.0 ± 3.8 mmHg), (p < 0.001). Conclusion: The laparoscopic complete excision of the posterior muscular cuff method was demonstrated as safe and efficient, with a decrease in the incidence of enterocolitis, although it may increase the number of soiling incidents in the short period post-surgery owing to a dissected partial internal anal sphincter.

Comparison of Hand-Sewn with Stapled Anastomosis in Neonatal Intestinal Atresia Surgery: A Randomized Controlled Study.

Objective: The purpose of this study was to compare the safety and efficacy of hand-sewn versus stapled anastomosis therapy in intestinal atresia neonatal patients. Materials and Methods: This was a prospective randomized controlled trial in which 90 neonates with intestinal atresia were randomly divided into the hand-sewn group and the stapled group. All patients were assigned to undergo intestinal anastomosis by hand-sewn or stapler. The primary outcome measure was to analyze the anastomotic complications between groups. The secondary outcome measures were operative time, blood loss, length to initial feeds, length to full feeds, length of hospital stay, the incidence of bowel obstruction, reoperation and mortality, and weight and height 1 year after operation. Results: A total of 82 patients were included (43 for hand-sewn and 39 for stapled group) for primary analysis. A total of 16 patients suffered from anastomotic complications in both groups. The incidence rate of anastomotic complications in the stapled group was significantly lower than that of the hand-sewn group (27.9% versus 10.3%, P = .044). There were no differences in anastomotic leak, stricture, and bleeding in the hand-sewn group compared with stapled group. The operative time in the hand-sewn group was longer than the stapled group (P < .001), the length to initial and full feeds in the stapled group was shorter than that of the hand-sewn group (P < .001). The length of hospital stay was significantly shorter in the stapled group than the hand-sewn group (P = .016). The bowel obstruction, reoperation, weight and height, and mortality had no differences between groups during follow-up. Conclusion: Study results demonstrate that stapled anastomosis is safe and effective for intestinal atresia with distal diameter >1 cm, as it can decrease the incidence of anastomotic complications. However, the risk of anastomotic failure should be considered among type III b atresia. Clinical Trial Registration number: NCT03754907.

E. coli JM83 damages the mucosal barrier in Ednrb knockout mice to promote the development of Hirschsprung­associated enterocolitis via activation of TLR4/p­p38/NF­κB signaling.

Hirschsprung­associated enterocolitis (HAEC) is characterized by intestinal mucosal damage and an imbalance in the intestinal microbiota. Recent studies have indicated that the TLR4/p­p38/NF­κB signaling pathway in the intestine is of great importance to intestinal mucosal integrity. The present study aimed to investigate the role of TLR4/phosphorylated (p­)38/NF­κB signaling in the pathogenesis of HAEC in E. coli JM83­infected endothelin receptor B (Ednrb)­/­ mice. Ednrb­/­ mice were infected with E. coli JM83 by oral gavage to establish the HAEC model. Wild­type and Ednrb­/­ mice were randomly divided into uninfected and E. coli groups. The role of TLR4/p­p38/NF­κB signaling was further evaluated by in vivo and in vitro analyses. The activation of the TLR4/p­p38/NF­κB signaling pathway induced by E. coli JM83 resulted in HAEC in Ednrb­/­ mice, which was evidenced by a significant increase in the expression of TNF­α, TGF­ß and IL­10, and a decreased density of F­actin protein expression. TLR4 knockdown reduced the severity of enterocolitis and attenuated the expression of IL­10, TNF­α and TGF­ß, whilst increasing the density of F­actin protein in Ednrb­/­ mice after E. coli infection. These results indicated that E. coli JM83 activates TLR4/p­p38/NF­κB signaling in Ednrb­/­ to promote the development of HAEC. Thus, inhibition of this signaling pathway may benefit the treatment and prevention of HAEC.

Application of Perioperative Transfusion Trigger Score in Patients Undergoing Surgical Treatment of Malignant Tumor.

The present study aimed to investigate the clinical effects of the brand new perioperative transfusion trigger score (POTTS) system in patients undergoing malignant tumor surgeries. 442 cases of patients diagnosed with malignant tumor were randomly selected (from January 2012 to December 2016) from Zunyi Medical University and were divided into 3 experimental groups. Patients in the POTTS group were transfused by the POTTS guideline perioperatively, while patients in the 7-10 g group were treated by the traditional transfusion guidelines existed (restrictive transfusion strategy), patients in the 10 g group should be transfused to keep the Hb level no less than 10 g/dL (liberal transfusion strategy). Baseline information, operation time, bleeding volume, transfusion amount, incision healing time, postoperative complications, metastasis and recurrence were observed and recorded. Postoperative short-term mortality was comparable of the 3 groups, 3 cases of death all occurred in 10 g group, there was no significant difference in the incidence of postoperative complications, including infectious complications and coagulation related complications. Follow-up to date, there were 25 cases, 29 cases and 29 cases of tumor recurrence and metastasis in the three groups, but no statistical difference observed. The present findings show that the POTTS transfusion system is more advantageous with regard to save blood and relieve economic burdens of patients, and does not affect the long-term recurrence and metastasis rate of malignant tumor.

Downregulation of P2Y2 and HuD during the development of the enteric nervous system in fetal rats with anorectal malformations.

Certain patients with anorectal malforma-tions (ARMs) continue to suffer from postoperative dysphoria. The enteric nervous system (ENS) is closely associated with defecation. The purinergic receptor P2Y2 (P2Y2) and Hu antigen D (HuD) proteins contain multiple motifs that enable their activation and direct coupling to integrin and growth factor receptor signaling pathways; thus, they may serve as key points in ENS development. The aim of the present study was to investigate the expression pattern of P2Y2 and HuD proteins during anorectal development in ARM embryos. The embryogenesis of ARM in rats was induced by ethylenethiourea (ETU) on the 10th gestational day. The expression patterns of P2Y2 and HuD proteins were evaluated by immunohistochemistry and western blot analysis in normal, ETU and ARM rat embryos on embryonic days E17, E19 and E21; their mRNA levels were assessed via reverse transcription­quantitative polymerase chain reaction (RT­qPCR) of the distal rectum of fetal rats. Immunohistochemistry of the distal rectum demonstrated that on E17, the expression levels of the two proteins were not different between the three groups. On E19, the expression of HuD was significantly decreased in the ARM group. On E21, the two proteins were significantly decreased in the ARM group. Additionally, the expression levels of the two proteins on E17 were significantly lower than on E21 in the ARM group. Western blotting and RT­qPCR also revealed that the P2Y2 and HuD proteins and mRNA expression levels were significantly decreased in the ARM groups when compared with the normal group on E17 and E21 (P<0.01). Thus, the present study demonstrated that downregulation of P2Y2 and HuD may partly be related to the development of the ENS in ARM embryos.

Transanal endorectal stepwise gradient muscular cuff cutting pull-through method: Technique refinements and comparison with laparoscopy-assisted procedures.

In all existing radical resection procedures available for Hirschprung's disease (HD), the muscular cuff has been retained. In recent years, our study group has modified the procedure using a stepwise gradient muscular cuff cutting pull-through method for the treatment of HD. The objective of the present study was to assess patient prognosis following the use of the transanal endorectal pull-through (TEPT) method or the laparoscopy-assisted pull-through (LPT) method and to provide evidence to assist in clinical decisions. The medical records of 172 patients (age, ≥3 years) who underwent TEPT or LPT for HD between September 2003 and August 2014 at the Pediatric Surgery Department of The Affiliated Hospital of Zunyi Medical College (Zunyi, China) were reviewed (TEPT, n=94; LPT, n=78). Preoperative, intraoperative and post-operative data for the subjects involved were recorded. Each patient's family was interviewed using a uniform 12-item post-pull-through long-term outcome questionnaire, which was scored in order to compare the short and long-term treatment outcomes of patients in each group. Patients in the LPT group had significantly prolonged operating times, reduced intraoperative blood loss and perioperative transfusion rates and shorter anal dissection times. Furthermore, the oral feeding time and length of hospital stay were similar between groups. There were no significant differences in early complications between the groups. No significant differences in late complications, including anastomotic stricture and enterocolitis were observed; however, the soiling and constipation rates were significantly higher in the TEPT group compared with the LPT group. The stool pattern score was not significantly different between groups, while the frequency of bowel movements in the LPT group was significantly higher compared with the TEPT group from 9-24 months post-surgery. The stepwise gradient muscular cuff cutting pull-through method demonstrated a good safety profile and efficacy with regard to the long-term outcomes of patients with HD. These results support the clinical application of LPT as a promising surgical approach for children with HD.

Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis.

Patients undergoing endoscopy frequently require sedation, which commonly includes the administration of midazolam or dexmedetomidine. Previous meta-analyses have mainly focused on comparing the effects of these two drugs in intensive care unit patients. In the present study, randomized controlled trials (RCTs) that compared the sedative and clinical effectiveness of these two drugs in patients undergoing endoscopy were searched in a number of databases. The meta-analysis showed that dexmedetomidine demonstrated a significantly lower rate of respiratory depression and adverse events compared with those presented upon midazolam administration. A significant difference was also observed in the sedation potency of the sedatives. The current controlled data suggest that dexmedetomidine may be an alternative to midazolam in the sedation for endoscopy. However, more high-quality and well-designed studies are required to further evaluate this conclusion.

Expression of the P2Y2 receptor in the terminal rectum of fetal rats with anorectal malformation.

OBJECTIVE: The expression and distribution of a subtype of purine receptors (P2Y2) in the terminal rectum of fetal rats with anorectal malformations (ARM) were examined to investigate their possible impact on the development of the enteric nervous system (ENS). METHODS: Pregnant Sprague-Dawley rats were randomly divided into a control group (5 rats) and an experimental group (20 rats). The experimental group was treated with ethylene thiourea (ETU). On gestational day 20, the intrauterine fetal rats were collected from both groups of pregnant rats. Sagittal sections of the pelvic perinea were stained with HE. P2Y2 protein and mRNA expression in the terminal recta of the fetal rats in the control group, the ARM group, and the ETU-treated group that exhibited no malformations (the ETU group) were detected by immunohistochemistry, western blot, and qRT-PCR. RESULTS: The fetal rats in the control group showed normal position of the anal opening, with no malformation. The incidence of ARM was 89.2% for the fetal rats in the experimental group. The immunohistochemistry results showed that P2Y2 was expressed in the cytoplasm of the cells in the terminal rectum submucosa and myenteric plexus of the fetus rats in the control group, the ETU group, and the ARM group. The average integrated optical density (IOD) value for the ARM group was significantly lower than the IOD value for the control and ETU groups (186.48 ± 23.03 vs. 493.18 ± 19.70; 186.48 ± 23.03 vs. 479.48 ± 41.71, P<0.01), while the IOD value for the ETU group was comparable to the control group IOD (493.18 ± 19.70 vs. 479.48 ± 41.71, P = 0.360). The western blot and qRT-PCR results showed that the P2Y2 protein and mRNA expressions were significantly lower in the terminal rectum of the fetal rats in the ARM group than in the control and ETU groups (0.28 ± 0.08 vs. 0.51 ± 0.10, 0.28 ± 0.08 vs. 0.48 ± 0.12; 48.91 ± 12.17 vs. 98.03 ± 15.68, 48.91 ± 12.17 vs. 92.53 ± 10.43; P<0.01), while the P2Y2 protein and mRNA levels in the control group were comparable to the ETU group (0.51 ± 0.10 vs. 0.48 ± 0.12, P = 0.494; 98.03 ± 15.68 vs. 92.53 ± 10.43, P = 0.058). CONCLUSION: P2Y2 may participate in and affect the development of ENS in the terminal rectum of fetal rats with ARM.