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Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.
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Toll-like receptors (TLRs) are major players in the innate immune system-recognizing pathogens and differentiating self/non-self components of immunity. These proteins are present either on the plasma membrane or endosome and recognize pathogens at their extracellular domains. They are characterized by a single transmembrane helix and an intracellular toll-interleukin-1 receptor (TIR) domain. Few TIRs directly invoke downstream signaling, while others require other TIR domains of adaptors like TIR domain-containing adaptor-inducing interferon-ß (TRIF) and TRIF-related adaptor molecule (TRAM). On recognizing pathogenic lipopolysaccharides, TLR4 dimerises and interacts with the intracellular TRAM dimer through the TIR domain to recruit a downstream signaling adaptor (TRIF). We have performed an in-depth study of the structural effect of two mutations (P116H and C117H) at the dimeric interface of the adaptor TRAM, which are known to abrogate downstream signaling. We modeled the structure and performed molecular dynamics studies in order to decipher the structural basis of this effect. We observed that these mutations led to an increased radius of gyration of the complex and resulted in several changes to the interaction energy values when compared against the wild type (WT) and positive control mutants. We identified highly interacting residues as hubs in the WT dimer, and a few such hubs that were lost in the mutant dimers. Changes in the protein residue path, hampering the information flow between the crucial A86/E87/D88/D89 and T155/S156 sites, were observed for the mutants. Overall, we show that such residue changes can have subtle but long-distance effects, impacting the signaling path allosterically.
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Background: The traditional postoperative visit consists of an in-person hospital visit at a predetermined date which requires the investment of time and resources. This implies a need to prioritize visits rather than mandating them, which can be assessed by the requirement of clinical intervention at the time of follow-up. The purpose of this study is to determine the clinical value of routine postoperative physical follow-up in common pediatric surgery conditions, to identify factors determining follow-up, and to estimate the cost of routine follow-up. Materials and Methods: Surgical data of 226 patients admitted for routine pediatric surgical procedures were collected. The postoperative period was documented in detail and interventions done either physically or telephonically at the time of follow-up were used as a proxy measure of clinical value. Results: There were 226 patients enrolled, of which 64.60% followed up physically in outpatient department and 35.40% followed up telephonically. Maximum percentage of patients with postoperative complications belonged to the group of laparotomy at 22.22%, followed by complicated appendicitis at 15.62%. 13.27% of patients required clinical intervention at the time of follow-up. Conclusion: Patients undergoing simpler procedures such as inguinal hernia, hydrocele, and orchidopexy have lesser rate of complications which translates to requirement of fewer clinic visits, whereas those undergoing procedures such as appendectomy and laparotomy require a physical visit after discharge since they are more susceptible to develop complications requiring interventions. By selecting patients for physical visit, we can potentially eliminate unnecessary visits in patients who have low chance of developing complications.
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Thoracoscopic surgery was not previously accepted in the neonatal population due to inappropriate instrumentation and lack of experience. However, our experience in the last few decades has slowly yet steadily established its safety and efficacy. The major advantages that thoracoscopy offers are early recovery and fewer long-term complications. However, we are aware that this comes at the cost of a steep learning curve and the potential challenge of facing certain complications which may compel a conversion to open. There is a paucity of literature regarding intraoperative complications of neonatal thoracoscopy and its management. Conversion to open thoracotomy is appropriate, keeping patient safety in mind, and any decision made to continue management of a complication thoracoscopically is technically demanding. Iatrogenic bronchial injury is one such rare complication of thoracoscopy with a limited mention in literature. We describe below a 25-day-old patient with a bronchogenic cyst who sustained injury to the left bronchus during thoracoscopic cyst excision, which was successfully repaired thoracoscopically.
