Clinical presentation, response to therapy, and outcome of gastroparesis in children.

OBJECTIVES: The aims of the present study was to define the clinical features, response to therapy, and outcome of pediatric gastroparesis. METHODS: Retrospective review of 230 children with gastroparesis. Demographics, gastric emptying times, symptoms, response to medications, and outcome were determined for each of 3 groups (infants, children, and adolescents). RESULTS: Mean age was 9 years, with boys predominating among infants and girls among adolescents. Postviral gastroparesis occurred in 18% and mitochondrial dysfunction (MD) in 8%. Symptoms varied with age, with children experiencing more vomiting and adolescents reporting more nausea and abdominal pain. The addition of promotility drugs was an effective therapy. Overall rates of symptom resolution were 22% at 6 months, 53% at 18 months, and 61% at 36 months, with median time to resolution of 14 months. Factors associated with symptom resolution included younger age, male sex, postviral gastroparesis, shorter duration of symptoms, response to addition of promotility therapy, and absence of MD. In multivariate analysis, longer duration of symptoms and MD both predicted lower rates of resolution, whereas younger age and response to addition of promotility therapy predicted a higher rate. CONCLUSIONS: Pediatric gastroparesis is a complex condition with variable symptomatology and outcome depending on multiple parameters. Understanding the clinical features and response to therapy will improve our diagnosis and treatment of this disorder.

Percutaneous treatment of thoracic duct injuries.

BACKGROUND: Major thoracic or neck surgery or penetrating trauma can cause injury to the thoracic duct and development of a chylothorax. Chylothorax results in metabolic and immunologic disorders that can be life threatening, with a mortality rate reaching 50%. The management of chyle leaks is dependent on the etiology and daily output. Interventions are used to treat only leaks unresponsive to medical management or those with an output exceeding 1,000 ml/day. METHODS: This study reviewed the existing literature on the percutaneous management of chyle leaks. The authors evaluated five case series and three case reports inclusive of 90 patients in which percutaneous treatment for chylothorax was attempted between 1998 and 2004. RESULTS: For 71 patients, percutaneous treatment was technically successful, and chylothorax resolved in 49 of the patients (69%). Percutaneous treatment of chylothorax was associated with a 2% morbidity rate and no mortality. For 19 patients whose percutaneous approach failed, either surgical ligation or pleurodesis was performed. CONCLUSIONS: The percutaneous management of chyle leak is feasible, with low morbidity and mortality rates and a high rate of effectiveness. This approach should be considered before more invasive procedures.

Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Studies reporting the revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been complex, underpowered, and lacking long-term data. We have previously shown that short-term (12-month) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. To report the midterm outcomes of LAGB after RYGB failure. METHODS: A retrospective review of prospectively collected data before and after RYGB, when available, and before and after LAGB was performed at the New York Langone University Hospital (New York, NY). The data collected included weight, height, body mass index (BMI), gender, race, age, operative time, length of stay, postoperative complications, and the percentage of excess weight loss. RESULTS: A total of 43 patients (9 men and 34 women) underwent LAGB after weight loss failure with RYGB. Of the 43 patients, 27 patients had undergone RYGB at other institutions, and preoperative RYGB data were available for 23 total patients. The average interval to LAGB was 6.6 years. The mean BMI before RYGB was 50.4 kg/m(2) and before LAGB was 43.3 kg/m(2) (%EWL was 17% after RYGB). At follow-up after LAGB, the average BMI was 35.2 kg/m(2), with a %EWL of 38% (calculated from LAGB only) at 26 months (range 6-66). At the 1- and 2-year follow-up visit, the BMI had decreased by 8.7 kg/m(2). The reoperation rate for complications related to LAGB was 10% and included 2 band erosions, 1 band slip, and 1 port flip. CONCLUSION: The results of our study have shown that LAGB had good midterm data as a revisionary procedure for weight loss failure after RYGB.

Mechanical dissociation of swine liver to produce organoid units for tissue engineering and in vitro disease modeling.

The complex intricate architecture of the liver is crucial to hepatic function. Standard protocols used for enzymatic digestion to isolate hepatocytes destroy tissue structure and result in significant loss of synthetic, metabolic, and detoxification processes. We describe a process using mechanical dissociation to generate hepatic organoids with preserved intrinsic tissue architecture from swine liver. Oxygen-supplemented perfusion culture better preserved organoid viability, morphology, serum protein synthesis, and urea production, compared with standard and oxygen-supplemented static culture. Hepatic organoids offer an alternative source for hepatic assist devices, engineered liver, disease modeling, and xenobiotic testing.