Improved outcomes for inborn babies with uncomplicated gastroschisis.

INTRODUCTION: Gastroschisis (GS) is a common abdominal wall defect necessitating neonatal surgery and intensive care. We hypothesized that inborn patients had improved outcomes compared to patients born at an outside hospital (outborn) and transferred for definitive treatment. METHODS: A single center, retrospective chart review at a pediatric tertiary care center was performed from 2010 to 2015. All patients whose primary surgical treatment of GS was performed at this center were included. We compared patients delivered within our center (inborn) to patients delivered outside of our center and transferred for surgical care (outborn). Babies with complicated gastroschisis were excluded. RESULTS: During the study period 79 patients with GS were identified. Of these, 53 were inborn and 26 were outborn. Sixteen patients were excluded for complicated GS. The rate of complicated GS was higher in the outborn group (32%) compared to the inborn population (11%) (p=0.03). Duration of stay, readmission rate and time on TPN were all significantly decreased for inborn patients, while time to definitive closure was similar. Mortality was 0% for both inborn and outborn patients. CONCLUSION: Patients with uncomplicated GS seem to benefit from delivery with immediate pediatric surgical care available eliminating the need for transfer. LEVEL OF EVIDENCE: III.

Management of chronic pancreatitis in the pediatric patient: endoscopic retrograde cholangiopancreatography vs operative therapy.

PURPOSE: The management of chronic pancreatitis (CP) in children is challenging. We compare endoscopic retrograde cholangiopancreatography (ERCP) to operative therapy (OR). METHODS: The study involved review of patients younger than 18 years with CP who underwent ERCP or OR from 1973 to 2007. Follow-up was complete in 95% of patients (median, 6 years; range, 1-23 years). RESULTS: We identified 37 children with CP; 25 (68%) were managed by OR with 20 of these previously failing ERCP. Twelve (32%) were managed by ERCP alone. Mean follow-up was longer in the OR group (5.1 vs 2.1 years; P = .02). Patients with idiopathic pancreatitis (58% vs 13%; P = .04) and patients with a later onset of pancreatitis (12.0 vs 7.4 years; P = .002) were more likely to be managed with ERCP alone. The patients who underwent OR had a lower rate of recurrent pancreatitis (39% vs 75%; P < .0001), although this did not correlate to fewer hospitalizations or less narcotic use compared to ERCP alone. When patients who failed ERCP and progressed to OR were included in the ERCP alone group, ERCP was worse in recurrence (90% vs 39%; P < .0001) and rate of hospitalization (55% vs 33%; P = .04) compared to OR. CONCLUSION: Patients with CP managed by OR have a lower rate of recurrent pancreatitis and hospitalization compared to ERCP.

Mechanisms of ileal adaptation for glucose absorption after proximal-based small bowel resection.

INTRODUCTION: The hexose transmembrane transporters SGLT1 and GLUT2 are present in low quantities in ileum where little glucose absorption occurs normally; however, glucose uptake in ileum is highly adaptable after small bowel resection. HYPOTHESIS: Ileal adaptability for glucose absorption after jejunal resection is mediated predominately by upregulation of GLUT2. METHODS: Rats underwent 70% proximal-based jejunoileal resection. Transporter-mediated glucose uptake was measured in proximal and distal remnant ileum 1 and 4 wk postoperatively (n = 6 rats, each) and in corresponding ileal segments in control and 1 wk sham laparotomy rats (n = 6, each) without and with selective inhibitors of SGLT1 and GLUT2. In separate groups of rats (n = 6, each), protein (Western blots), mRNA (reverse transcriptase polymerase chain reaction [RT-PCR]), and villus height (histomorphology) were measured. RESULTS: After 70% proximal intestinal resection, there was no dramatic change in protein or mRNA expression per cell of either SGLT1 or GLUT2, but median glucose uptake (nmol/cm/min) increased markedly from 52 (range 28-63) in controls to 118 (range 80-171) at 1 wk, and 203 (range 93-248) at 4 wk (p < or = 0.04 each) correlating with change in villus height (p < or = 0.03). CONCLUSIONS: Ileal adaptation for glucose transport occurs through cellular proliferation (hyperplasia) and not through cellular upregulation of glucose transporters.

Effects of extrinsic denervation on innervation with VIP and substance P in circular muscle of rat jejunum.

Extrinsic denervation contributes to enteric motor dysfunction after small bowel transplantation (SBT). Our aim was to determine changes in nonadrenergic, noncholinergic innervation with vasoactive intestinal polypeptide (VIP) and substance P (Sub P) in rat jejunal circular muscle after SBT. Muscle strips were studied in tissue chambers from six groups of rats (n > or = 6 per group): naïve controls (NC), animals 1 week after anaesthesia/sham celiotomy (SC-1), and 1 and 8 weeks after jejunal and ileal transection/reanastomosis (TA-1, TA-8) and after syngeneic, orthotopic SBT (SBT-1, SBT-8). Response to exogenous VIP and Sub P and their endogenous release during electrical field stimulation (EFS) were studied. Exogenous VIP and Sub P caused a dose-dependent inhibition and stimulation of mechanical activity in all groups respectively (P < 0.05). The responses to VIP and Sub P were decreased (compared to NC) in all groups at 1 and 8 weeks postoperatively. The VIP antagonist ([D-p-Cl-Phe(6),Leu(17)]-VIP) did not prevent the inhibition by exogenous VIP in any group, while the Sub P antagonist ([D-Pro(2),D-Trp(7,9)]-Sub P) prevented the effect of exogenous Sub P in NC, TA-8 and SBT-8 (P < 0.05). Responses to exogenous VIP were unaffected by the nitric oxide synthase inhibitor l-N(G)-nitro arginine and precontraction of muscle strips with Sub P. Endogenous release of VIP and Sub P during EFS was preserved after SBT. In circular muscle of rat jejunum, changes in neuromuscular transmission with VIP and Sub P during the first 8 weeks after SBT are not mediated by extrinsic denervation.

Effect of chronic, extrinsic denervation on functional NANC innervation with vasoactive intestinal polypeptide and substance P in longitudinal muscle of rat jejunum.

Intestinal denervation contributes to enteric motor dysfunction after intestinal transplantation [small bowel transplantation (SBT)]. Our aim was to determine long-term effects of extrinsic denervation on functional non-adrenergic, non-cholinergic innervation with vasoactive intestinal polypeptide (VIP) and substance P. Contractile activity of jejunal longitudinal muscle from six age-matched, naïve control rats (NC) and eight rats 1 year after syngeneic SBT were studied in tissue chambers. Spontaneous contractile activity did not differ between groups. Exogenous VIP inhibited contractile activity dose-dependently in both groups, greater in NC than in SBT. The VIP antagonist ([D-p-Cl-Phe(6),Leu(17)]-VIP) and the nitric oxide synthase inhibitor l-N(G)-nitro arginine prevented inhibition by exogenous VIP and electrical field stimulation (EFS) in both groups. Exogenous substance P increased contractile activity dose-dependently, greater in NC than in SBT. The substance P antagonist ([D-Pro(2),D-Trp(7,9)]-substance P) inhibited effects of exogenous substance P and increased the EFS-induced inhibitory response. Immunohistofluorescence showed staining for tyrosine hydroxylase in the jejunoileum 1 year after SBT suggesting sympathetic reinnervation. In rat jejunal longitudinal muscle after chronic denervation, response to exogenous VIP and substance P is decreased, while endogenous release of both neurotransmitters is preserved. These alterations in excitatory and inhibitory pathways occur despite extrinsic reinnervation and might contribute to enteric motor dysfunction after SBT.

Bariatric surgery at the extremes of age.

The safety and efficacy of bariatric surgery in adolescents and especially in Medicare population have been challenged. Our aim was to determine short-term (30-day) and long-term outcomes of bariatric surgery in patients>or=60 years and or=60 years and 12 patientsor=60 years and all 12 adolescents returned the questionnaire (92%) at a mean of 5 years (range 1-19 years). For patients>or=60 years, 30-day mortality was 0.7%, serious morbidity delaying discharge was 14%, and 5-year mortality was 5%. At a mean of 5 years, body mass index (BMI in kg/m2) decreased from a mean (+/-SEM) of 46+/-1 to 33+/-1 with a 51% resolution of weight-related comorbidities and an 89% subjective overall satisfaction rate. In patients