Anastomosis In Children Research Articles

Laparoscopic interventions in children with cystic bile duct dilations

Aim. To evaluate the efficacy of laparoscopic interventions and to carry out a comparative analysis of various options for biliodigestive anastomoses in children with cystic dilation of bile ducts. Materials and methods. The results of laparoscopic interventions were retrospectively analyzed in 110 children aged 2 months – 17 years with cystic bile duct dilation. Conversion was required in 3 observations (2.7 %). Laparoscopically assisted or total laparoscopic extirpation of dilated bile ducts with hepaticojejunostomosis was performed in 83 patients (75.5 %), laparoscopic surgery with hepaticoduodenostomosis – in 24 patients (21.8 %). Results. The duration of surgery was significantly shorter when hepaticoduodenoanastomosis was formed. After laparoscopic interventions, early complications were revealed in 10 observations (9.3 %), including 7 cases (6.5 %) of hepatico-duoduodenoanastomosis failure in which relaparotomy was performed with reconstruction of both interintestinal and biliodigestive anastomosis. Late postoperative complications (anastomotic stenosis and adhesive intestinal obstruction) developed in 11 patients (10.2 %). In 5 observations (4.6 %), percutaneous transhepatic cholangiostomy with staged balloon dilation of hepaticojejunostomosis (n = 3) and endoscopic balloon dilation of hepaticoduodenostomosis with stenting (n = 2) were performed with a positive effect. Conclusion. Resection of bile ducts with cystic dilations with the formation of biliodigestive anastomosis can be performed both via video-assisted surgery and completely laparoscopically. Laparoscopic interventions in children with different variants of cystic dilation of the bile ducts prove to be effective and safe.

Safety and advantages of early oral feeding after intestinal anastomosis in children: Our experience

Background: Restoration of enteral feeding is believed to enhance recovery after surgery, but intestinal anastomosis is a matter of apprehension for surgeons to start enteral feeding early. Before 2022, our standard practice was to wait three to four days to begin oral feeding after intestinal anastomosis. Since 2022, we have allowed oral feeding to start within 24 hours of intestinal anastomosis. This study compares the safety and benefits of early oral feeding after intestinal anastomosis in children. Methods: This retrospective study was done in the neonatal and paediatric surgery department, BSH&I, from January 2021 to December 2022. Children who received early oral feeding in 2022 compared with children who received oral feeding after three days in 2021. Children with duodenal anastomosis and anastomosis with a covering stoma were excluded. Demographic and clinical data were extracted from hospital records using a predefined questionnaire. Data were analyzed in SPSS 26, and a p-value <0.05 was considered significant. Results: One hundred thirty-three children (90 in 2022 and 43 in 2021) underwent intestinal anastomosis. Fiftynine (44.4%) children had small gut anastomosis, 62 (46.6%) children had large gut anastomosis, and 12 (9%) children had ileocolic anastomosis. There was no difference in gender and mean age at the surgery between the two groups. The mean time to start oral feeding was 19.9±0.59 hours in the case group and 79.1±13.9 hours in the control group (p<0.001). The mean time to full oral feeding was 61.05±4.5 hours in the case group and 125.67±25.51 hours in the control group (p<0.001). The mean hospital stay was 4.16±1.18 days in the case group and 7.06±1.96 days in the control group (p<0.001). The two groups had no significant differences in anastomotic and wound complications. Conclusion: Early oral feeding after intestinal anastomosis is safe in children and reduces postoperative hospital stay without any added risk. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 22-25

Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients.

Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications. We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification. Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months. According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.

Сomplications and functional outcomes after restorative proctocolectomy with ileal pouch–anal anastomosis in children: A single-center experience

BACKGROUND: Restorative proctocolectomy with ileal pouchanal anastomosis is a prominent treatment for adult patients with ulcerative colitis and familial adenomatous polyposis, with satisfactory functional outcomes. In literature, that technique in pediatric practice is described; however, in the domestic literature, there is no mention of ileal pouchanal anastomosis in children.
 AIM: This study aimed to examine the outcomes of ileal pouchanal anastomosis in pediatric patients.
 MATERIALS AND METHODS: The study comprised 33 patients with an ileal pouchanal anastomosis between January 2019 and June 2023. At the time of the ileal pouchanal anastomosis, the average age was 13 (5) yr. Patients were followed for an average of 17 (14) months.
 RESULTS: Patients with ulcerative colitis underwent three-stage surgical interventions more often than patients with another diagnosis (90% vs. 4%, p 0.0001), and the mean duration of surgery in ulcerative colitis patients was shorter than in patients with polyposis syndromes or total agangliosis: 173 (57) min versus 280 (73) min. Late complications were reported in five (15%) patients undergoing ileal pouchanal anastomosis. After the ileal pouchanal anastomosis, analysis of patient questionnaires revealed that children had satisfactory functional results.
 CONCLUSIONS: Several encouraging studies have confirmed good functional outcomes after ileal pouchanal anastomosis. Our findings suggest that ileal pouchanal anastomosis in children is associated with favorable results.

Intestinal anastomoses in children: Experience of pediatric surgeons in the Russian Federation

BACKGROUND: In pediatric surgery, intestinal anastomosis is a standard and responsible operative method used for all age groups. Although advancements in medical technology have significantly changed and expanded the range of surgical interventions, many questions remain, including the safety of intestinal anastomosis in newborns with significant segment discordance, the use of laparoscopic intestinal sutures, the use of mechanical stitching devices, and intestinal anastomosis in peritonitis.
 AIM: To determine current problems and future directions in the field of intestinal anastomosis in children in the Russian Federation.
 MATERIALS AND METHODS: The study is based on data from 4,558 intestinal anastomosis operations, including 1,735 in newborns, provided by the chief pediatric surgeons of 75 constituent entities of the Russian Federation during 20212022, including the Donetsk and Lugansk Peoples Republics. Based on a questionnaire, the data were summarized and statistically processed.
 RESULTS: The study reports on the results of intestinal anastomosis in children in the Russian Federation across various segments of the intestine and age groups. The risks of failure and re-reconstruction significantly increased when duodenal anastomosis was performed laparoscopically and in settings of peritonitis or a compromised intestinal wall (p 0.05). Conversely, the use of laparoscopy and suturing devices in older children for small intestine anastomosis was carried out practically without complications. However, it was performed twice as often in emergencies and against the background of combined problems. In general, the results of small bowel anastomosis under poor conditions were statistically insignificant from intestinal anastomosis with stoma closure (p 0.05). The data revealed that colon surgery, repeated reconstructions, duodenal anastomoses, and small intestine anastomoses in newborns with poor blood flow to the intestinal wall posed the highest risks of anastomotic failure. Small and large intestine surgery in newborns has the highest mortality rate, particularly with peritonitis and circulatory disorders.
 CONCLUSIONS: Thus at the current stage of development, intestinal anastomosis in the Russian Federation is characterized by good results, the expansion of indications for anastomosis in conditions of compromised intestine or peritonitis, and the use of laparoscopic techniques and mechanical staplers.

Early versus Delayed Enteral Nutrition after Gastrointestinal Anastomosis in Children: A Systematic Review and Meta-Analysis

Abstract Background Elective intestinal anastomosis is a frequently used surgical procedure in pediatric surgery. This option is used to restore intestinal continuity (ileostomy or colostomy closure), resolve an inflammatory disease or functional or anatomic congenital malformation. It is a common practice to avoid oral feeding in children after intestinal anastomosis surgery, traditionally from 3-5 days. Recently, interest has increased in the concept of early enteral nutrition (EEN) in abdominal surgery in adults, but it needs further research in children. Aim of the Work The aim of this study is to determine whether early enteral nutrition following elective gastrointestinal anastomosis surgery in children leads to improved patient outcome measures and to assess whether this practice increases the risk of postoperative complications, according to literature published in the period from 2010- 2020 Patients and Methods We searched PubMed, Cochrane, Embase, Google scholar, Egyptian Knowledge Bank including Science Direct, Scopus and Web of Science. Data from 2010 – 2020 were obtained using the following Medical Subject Headings (MeSH) terms. For the early aspect of nutrition, we used the MeSH terms ‘‘early’’ or ‘‘enhanced recovery’’ and ‘‘enteral nutrition’’ or ‘‘feeding’’. For the surgical background, we used the MeSH terms ‘‘gastrointestinal’’ or ‘‘bowel/intestinal’’ or ‘‘colorectal’’ and ‘‘surgery’’ or ‘‘anastomosis’’ or ‘‘resection,’’ while for the population we used the terms ‘‘child’’ or ‘‘pediatric’’ or ‘‘infant’’. Multiple outcomes were used. The softwares Review Manager (RevMan 5.3, The Cochrane Collaboration) and STATA (Stata Corp. 2007) were used to analyse the data and formulate the results. Results Seven RCT studies met the inclusion criteria, comprising 278 cases with EEF and 323 cases with DEF. Enteral feeding started significantly earlier in the EEF group compared to the DEF group (MD = -69.43; 95% CI -72.20 to -66.65; p < 0.0001). The EEF group had an earlier time to first bowel movement (MD -18.18; 95% CI -27.04 to -9.32; p < 0.0001), an earlier time to full diet intake (MD -103.50; 95% CI -126.63 to -80.37; p < 0.00001) and a shorter length of hospital stay (MD -3.57; 95% CI -4.4 to -2.74; p < 0.00001). There was no significant difference in incidence of nausea and vomiting (OR = 1.36; 95% CI 0.56, 3.30; p = 0.5), abdominal distension (OR = 1.68; 95% CI 0.80, 3.53; p = 0.17) or anastomotic dehiscence (OR = 0.58; 95% CI 0.19, 1.75; p = 0.34) between groups. There was significant difference between groups in surgical site infection (OR = 0.27; 95% CI 0.13, 0.57; p = 0.0005) and fever (OR = 0.32; 95% CI 0.16, 0.61; p = 0.0007) in favour of EEN. Conclusion When early enteral nutrition was compared to traditional delayed feeding, results showed that EEN is safe and effective in pediatric patients undergoing elective intestinal anastomosis.

Intestinal anastomoses in children: The draft decision of the Russian Symposium of Children surgeons (April 2023)

The Symposium of Pediatric Surgeons of Russia, Intestinal Anastomoses in Children, was conducted in Volgograd on April 26, 2023, with around 180 doctors in attendance. Thirty papers were presented and discussed, and 41 articles were published in the proceedings of the symposium. According to the results of a systemic analysis of a questionnaire poll of major pediatric surgeons in 75 regions of Russia, 4,558 surgeries on intestinal anastomosis formation were performed in 20212022, including 1,735 operations in newborn children (36%); their share in general pediatric surgery was less than 0.6%, and it was more than 18.6% in neonatal surgeons. The number of intestinal anastomoses formed during laparoscopic procedures increased (4.4%). Pediatric surgeons equally often used double-row nodal intestinal sutures (33.3%), single-row continuous sutures (34.6%), and different types of sutures (33.3%). A T-shaped anastomosis was performed in cases of necrotizing enterocolitis where there was a significant difference in the diameters of the intestine's inflow and outflow channels. The clip-and-drop technique was used to treat neonates with multifocal necroses. Interintestinal anastomoses were favored over enterostomies in numerous segmental resections. For duodenal obstruction, duodeno-duodenal, and duodeno-jejunal anastomoses were performed. In children with Crohn's disease and choledochal cysts, most specialists prefer operations with stapling devices. Creating a magnetic interintestinal anastomosis lowers the risk of postoperative complications and facilitates the postoperative period. Clinical observations after laparoscopic surgeries accounted for a significant proportion of complications (66%). Anastomosis failure was three times more common in planned small intestinal in older children than in emergency surgeries (1.2 and 0.4%, respectively).
 The modern stage of development of intestinal anastomosis formation techniques in children is characterized by good results, the expansion of indications for intestinal anastomosis in conditions of compromised colon or peritonitis, and the introduction of laparoscopic techniques and mechanical stapling devices with slightly poorer results.

Laparoscopic partial internal biliary diversion through a cholecystojejunocolonic anastomosis in children: Report of a case series with a novel simplified approach

BackgroundBiliary diversion techniques have been described as an alternative for the treatment of intractable pruritus due to chronic cholestasis. The aim of this study was to describe a simplified partial internal biliary diversion by laparoscopy and to evaluate the results in these patients. MethodsBetween 2017 and 2021, three children with chronic cholestasis disease underwent Laparoscopic partial internal biliary diversion (Lapin-PIBD). The etiologies were: Alagille Syndrome, Arthrogryposis-Renal dysfunction-Cholestasis and cholestatic liver disease associated with KMT2D mutation. Laparoscopic procedure included: mobilization of the ascending colon, jejunal bowel exteriorization through the umbilical incision and creation of an isoperistaltic jejunal segment. Jejuno-jejunal anastomosis and jejuno-colonic anastomosis were performed extracorporeally. Proximal jejunum was anastomosed to the fundus of the gallbladder using intracorporeal interrupted sutures. In one case Indocyanine green (ICG) fluorescence was used to evaluate the passage of the bile through the conduit and the bowel vascularization. ResultsThree patients underwent Lapin-PIBD successfully. The median weight was 10.8 kg (5.6–16). All patients showed reduction of pruritus and liver enzymes levels at three months postoperatively. Mean follow-up was 28 months and none of the children had complications. ConclusionsLapin-BD through cholecystojejunocolonic anastomosis is an effective treatment of severe pruritus in patients with chronic cholestasis improving their quality of life. It offers the advantages of minimally invasive surgery and reduces the abdominal adhesions in patients who may require a liver transplant in the future.Level of Evidence:IV

Stapled versus hand-sewn intestinal anastomosis in pediatric patients: a systematic review and meta-analysis

BackgroundThe safety and feasibility of stapled intestinal anastomosis have been widely reported in adults. However, the efficacy of stapled anastomosis (SA) in children is unclear. The aim of this study was to perform a systematic review and meta-analysis to evaluate the safety and effectiveness of SA compared with hand-sewn anastomosis (HA) in pediatric patients.MethodsA systematic literature search was performed using PubMed, the Cochrane Library, and Scopus databases. Studies comparing outcomes of children aged < 7 years and subgroups of children aged < 1 year who underwent SA or HA were included. Primary outcomes were anastomotic leakage and anastomotic stricture. Mean differences (MDs) with 95 % confidence intervals (CIs) were calculated for continuous variables. Odds ratios (ORs) with 95 % CIs were calculated for dichotomous variables. Interstudy heterogeneity was assessed using the chi-squared test and was quantified using the I² statistic.ResultsOne randomized control trial and five retrospective cohort studies, comprising 633 cases (229 SA cases and 404 HA cases), were included. No significant differences were observed in anastomotic leakage (6.5 % vs. 7.4 %; OR, 0.93; 95 % CI, 0.37–2.34; p = 0.88), anastomotic stricture (4.1 % vs. 9.3 %; OR, 0.54; 95 % CI, 0.19–1.51; p = 0.24), ileus (7.1 % vs. 9.3 %, OR, 2.35; 95 % CI, 0.15–37.51; p = 0.54), anastomosis-related complications (9.5 % vs. 10.9 %, OR, 0.98; 95 % CI, 0.52–1.86; p = 0.96; I2 = 39 %), and time until full-feeding (MD = -3.57 days; 95 % CI, -11.36 to 4.23; p = 0.37) between SA and HA. Operative time was significantly shorter in SA than in HA in children aged < 1 year (MD = -20.36 min; 95 % CI, -26.13 to -14.59).ConclusionsSA required shorter operative time and was comparable to HA in the overall complication rate. Although the evidence was insufficient, SA could be an option for intestinal anastomosis in children.

Laparoscopic robotic-assisted restorative proctocolectomy and ileal J-pouch-anorectal anastomosis in children.

Total proctocolectomy with ileal J-pouch-anorectal anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC) in children. Considering the well-known advantages of minimally invasive approach, and its main application for the deep pelvis, robotic surgery may be used in UC reconstructive procedures. The aim of the study is to report our experience with Robotic IPAA in children. Single surgeon experience on Robotic IPAA were prospectively included. Data on patient demographics, surgical details, complications, and length of stay (LOS), were collected. Fifteen patients were included. Median age was 13.2years, median body weight 45kg. Median operative time was 240min. Median LOS was 7days and mean follow-up time 1year. No intraoperative complication occurred. Five postoperative complications happened: 3 minors treated conservatively (CD I-II), 2 majors needing reintervention under anesthesia (CD IIIb). No mortality was observed. Our preliminary experience reveals that Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. A bigger patient sample and a long-term follow-up are needed to confirm our findings.

Use of 5-mm Staple in Neonatal Intestinal Surgery.

Introduction: The use of staples to perform intestinal anastomosis in children has gained popularity in the past years. The aim of this study is to evaluate the outcomes of pediatric patients who underwent intestinal anastomosis with a 5-mm staple in a tertiary health care center. Material and Methods: From April 2017 to November 2019, the records of all pediatric patients who underwent intestinal anastomosis with a 5-mm staple were retrospectively revised. The reconstruction technique was functional end-to-end anastomosis. Results: A total of 12 intestinal anastomoses were evaluated. Mean age at surgery was 120 days. Small bowel anastomosis was the most frequently performed procedure (eight cases). Stapling difficulties were found in 3 patients. The anastomosis could not be performed with the 5-mm endostapler in one of these patients. The median follow-up was 26 months (interquartile range 20-40 months). Postoperative complications included one bowel obstruction that was surgically treated. Conclusions: Mechanical suturing with 5-mm staple is a safe alternative technique to perform intestinal anastomosis in neonates and infants. The use of this staple has proven to be safe and feasible in pediatric patients. It is necessary to select patients carefully according to their bowel characteristics.

Surgical correction for scimitar syndrome by right thoracotomy and direct anastomosis in children.

ABSTRACTImportanceScimitar syndrome (SS) is a rare type of congenital heart disease characterized by total or partial anomalous venous drainage of the right lung to the inferior vena cava. However, the surgical repair techniques for SS vary according to patients’ anatomical and pathological features.ObjectiveThis study was performed to analyze the mid‐term results of a less invasive surgical correction technique for SS in children.MethodsEleven patients with SS who underwent surgical repair from January 2012 to March 2020 were retrospectively analyzed. The anomalous scimitar vein (SV) was directly reimplanted to the left atrium, and the concomitant atrial septal defect was simultaneously repaired with cardiopulmonary bypass.ResultsThree male and eight female patients were included in the study. Their mean age was 3.1 ± 1.3 years, and their mean body weight was 12.8 ± 3.0 kg. Most patients had symptoms, such as upper respiratory tract infection, dyspnea, and recurrent pneumonia, and two patients had pulmonary hypertension. None of the 11 patients who underwent direct SV reimplantation by right thoracotomy developed bleeding, arrhythmia, heart failure, or perioperative death, and no patients required reoperation during a mean follow‐up period of 36.6 ± 15.2 months. Postoperative echocardiography revealed no restenosis or obstruction of the anastomosis in any patients.InterpretationSurgical repair for SS by right thoracotomy and direct anastomosis of the SV to the posterior wall of the left atrium is safe and effective, with good long‐term patency of the reimplanted SV and a low mortality rate.

Early enteral feeding after intestinal anastomosis in children: a systematic review and meta-analysis of randomized controlled trials.

Delayed enteral feeding (DEF) contributes to postoperative complications among children undergoing intestinal surgery. Various recent studies indicate the benefits of early enteral nutrition after intestinal surgery in adults. This systematic review and meta-analysis evaluates whether early enteral feeding (EEF) is beneficial in children who underwent intestinal anastomosis. MEDLINE, PubMed, the Cochrane Library, and Web of Science databases were searched for RCTs that addressed the effect of EEF in children (younger than 18years old) undergoing intestinal anastomosis. EEF was defined as starting enteral feeding before the 3rd postoperative day. Studies were selected based on predetermined inclusion and exclusion criteria. A meta-analysis was performed using RevMan 5.3 to estimate odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs). Four RCT studies met the inclusion criteria, comprising 97 cases with EEF and 89 cases with DEF. Enteral feeding started significantly earlier in the EEF group compared to the DEF group (MD = - 2.80; 95% CI - 3.11 to - 2.49; p < 0.00001). Postoperative anastomotic leak rate was unchanged between EEF and DEF groups (OR = 0.86; 95% CI 0.17-4.46; p = 0.86). The EEF group had a shorter length of hospital stay (MD = - 3.38; 95% CI - 4.29 to - 2.48; p < 0.00001), earlier time to bowel movement return (MD = - 0.57; 95% CI - 0.79 to - 0.35; p < 0.00001), lower incidence of surgical infection (OR = 0.27; 95% CI 0.08-0.90; p = 0.03), and faster tolerance of full enteral feeding (MD = - 2.00; 95% CI - 3.01 to - 2.79; p < 0.00001). Incidence of fever (OR = 0.37; 95% CI 0.10-1.31; p = 0.12), emesis, and abdominal distention (OR = 0.63; 95% CI 0.13-3.16; p = 0.58) were not different between the two groups. Early enteral feeding after intestinal anastomosis in children does not increase the risk of postoperative anastomotic leak, fever, emesis, and abdominal distention. However, early enteral feeding is beneficial as it promotes the return of bowel function, reduces the length of hospital stay and the incidence of surgical infection in comparison to delayed enteral feeding.

Potts anastomosis in children with severe pulmonary arterial hypertension and atrial septal defect.

AimsPotts shunt has been proposed as a bridge or alternative to lung transplantation for children with severe and drug‐refractory suprasystemic pulmonary arterial hypertension (PAH). We describe the management of the atrial shunt when a Potts shunt is planned in refractory PAH.Methods and resultsWe report a case series of children in whom a Potts shunt was done for severe PAH associated with an atrial septal defect to illustrate the different clinical and haemodynamic scenarios. Five children (2 to 13 years) underwent a Potts shunt: three surgical, one percutaneous Potts shunt, and one percutaneous stenting of a restrictive arterial duct. All had associated atrial septal defect. Those who had generalized cyanosis before the procedure had a complicated postoperative course and required longer ventilatory and inotropic support, except the one who had atrial septal defect closure before the Potts shunt. One of the three cyanotic patients died. Two patients with left‐to‐right shunt before the Potts shunt had an uncomplicated postoperative course.ConclusionsShunt physiology is only partially predictable after the Potts shunt in children with PAH and atrial septal defect. Abrupt drop in left ventricle preload while the right ventricle is decompressed can potentially be prevented by atrial septal defect closure prior to the Potts shunt.

Перший в Україні досвід застосування лінійних степлерів при накладанні ентероанастомозу у дітей

Introduction. Conducting reconstructive surgery in children, especially those with low body weight, associated with an increase in the operation time and a worsening of the postoperative period. Therefore, to reduce the operation time, surgical clinics in developed countries of the world use linear staplers for anastomoses in children, especially young children. Case report. A premature newborn, with a birth weight of 1420 g, was diagnosed with necrotizing enterocolitis, with ileal perforation and diffuse peritonitis. According to vital indications, the operation was performed: laparotomy, revision of the abdominal cavity, Mikulich enterostomy. After complete stabilization of the general condition of the child, upon reaching 2550 g of body weight, at the age of 2 months, enterostomy closure was performed with the imposition of a stapled side-to-side functional end-to-end ileoileostomy. In 14 days after the operation, the child achieved full enteral autonomy. There were no postoperative surgical complications. In the late postoperative period, the child gains weight well, grows and develops according to age. Conclusion. The use of linear staplers in time of enteroanastomoses creation can significantly reduce operation time in children, in particular, premature babies with low body weight. Level of evidence. Level V. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of an participating institution.The informed consent of the child’s parents was obtained from the studies. No conflict of interest was declared by the authors. Key words: linear staplers, enteroanastomosis, necrotizing enterocolitis, perforation of the small intestine, newborn premature baby.

The effect of diversion on readmission following ileal pouch-anal anastomosis in children

BackgroundReadmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. MethodsChildren (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. ResultsNinety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation.Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. ConclusionReadmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. Level of EvidenceLevel III.

Evaluation of Both Single Layer Simple Interrupted Extramucosal Sutures and Single Layer Interrupted Connell Sutures for Intestinal Anastomosis in Children in Elective and Emergency Laparotomy

Background: Intestine anastomosis in pediatric surgery is a relevant matter because of the frequency of the procedure, nonetheless, there is no general agreement about the most appropriate surgical technique, nor are there records comparing the different methods in children. To validate the better technique in children, it is necessary to have clinically comparative experimental studies. Objective: the aim of this work is to evaluate both single layer simple interrupted extramucosal and single layer interrupted Connell sutures for intestinal anastomosis in children in elective and emergency laparotomy as regard technical, functional and financial aspects. Patients and Methods: his study was carried out on 40 patients candidate for intestinal anastomosis in elective and emergency laparotomy managed at Pediatric Surgery Department, Al-Azhar University in Cairo throughout the period from January 2017 to May 2019. Results: As regard the most frequent diagnosis or cause for anastomosis in our study, jejunal atresia was the most common cause of anastomosis with 9 cases (45%) in the extramucosal group and one case (5%) in the Connell group, then the intussusception with 2 patients (10%) in the extramucosal group, and 7 patients (35%) in the Connell group, then ileal atresia, 3 patients (15%) in the extramucosal group, and one patient (5%) in the Connell group. Conclusion: We concluded that both techniques for intestinal anastomosis are effective, safe and successful. We prefer single-layer interrupted extramucosal technique in elective and emergency laparotomy due to less operative time, and valuable cost-effectiveness.

Is there a functional disadvantage to using the external iliac vessels for vascular anastomosis in children and adolescents undergoing renal transplantation?

RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size. Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA. Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8±11.5 and 4.3±5.0; P<0.001), preoperative need for dialysis (9.7±11.0 and 6.5±6.0, P=0.02), location of arterial anastomosis (aorta [n=21] 4.9±6.1, common iliac [n=93] 7.1±7.3, external iliac 14.7±14.5; P<0.001, Figure 1B) and venous anastomosis (vena cava [n=21] 5.6±6.3, common iliac [n=89] 7.1±7.6, external iliac [n=44] 13.8±14); P<0.001). On multivariable analysis, this association remained statistically significant when adjusting for recipient age, height, BSA, donor source, change in blood pressure with unclamping, and use of inotropes and preoperative dialysis. The detrimental effect on ttNC was more salient when comparing external iliac vs common iliac and aorta or vena cava. Our data suggest that anastomosis to a smaller caliber target vessel (ie, external iliac) in comparison with the common iliac or aorta/vena cava may be a risk factor for delayed return of graft function, independent of recipient size and donor source. This finding merit further evaluation, as it may help with intraoperative decision making during pediatric and adolescent RT.

Does Age Affect Surgical Outcomes After Ileal Pouch–Anal Anastomosis in Children?

BackgroundYounger children are referred for surgical intervention in the treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Outcome data in this population after a laparoscopic restorative proctocolectomy and Ileal pouch-anal anastomosis (LRS-IPAA) are limited. We reviewed our experience to determine if younger children would have similar functional outcomes. MethodsAfter institutional review board approval, a review of children with FAP and UC undergoing LRS-IPAA at a children's hospital from 2002 to 2017 occurred. The study groups were defined based on age: young group (YG; 5-12 y) and older group (OG; 13-18 y). Data points included demographics, postprocedure course, and outcomes. Statistical analysis was performed. ResultsSixty-five children were identified and grouped by age: YG (n = 22, average age 9 y) and OG (n = 43, average age 15.4 y). Thirteen children in YG had UC, and nine had FAP. Twenty-eight children in OG were diagnosed with UC, and 15 with FAP. After LRS-IPAA, continence, appetite recovery, and use of antidiarrheal medications were not significantly different between groups. The incidence of pouch stricture, diagnosis of pouchitis, and complications were also not significantly different. Two children (YG), aged 11 and 12 y at the time of colectomy, were initially diagnosed with UC and then reassigned as having Crohn's disease because of persistent symptoms. One child, who underwent colectomy at 17 y for FAP, had invasive rectal cancer and died 3 y later from metastatic disease. Time of follow-up for OG is 8-61 mo (average: 37 mo). Period of follow-up for YG is 11-73 mo (average: 43 mo). ConclusionsThere are no significant differences in the functional outcomes between groups after LRS-IPAA. Although numbers are small, these data suggest younger age should not be a deterrent when contemplating LRS-IPAA in the treatment of UC and FAP in the pediatric population. Younger patients with FAP may benefit from early intervention.

Early Enteral Nutrition Following Gastrointestinal Surgery in Children: A Systematic Review of the Literature.

To investigate the safety and effectiveness of early enteral feeding versus traditional enteral feeding after gastrointestinal (GI) anastomosis in children in the pediatric literature. Prolonged postoperative fasting has been the traditional model of care following pediatric GI surgery. In contrast, early feeding has become well established in the adult population, where meta-analyses have shown early introduction of enteral feeds to be beneficial to hospital stay and patient outcomes. Comprehensive literature searches of the English literature search (PubMed, Ovid, Embase databases) from inception to present according to the PRISMA guidelines. Included studies were assessed according to the MINORS criteria. Outcomes for time to first feed and full feeds, and discharge, and risk of major complications were synthesized. Ten studies comprising 451 patients were included in the analysis. All studies aimed at investigating the safety of early feeding in pediatric GI surgery, with or without a fast-track program. Only 4 studies compared the study group to a control group in which patients were fed in a traditional way (traditional feeding).Most studies defined early feeding as feeds commenced ≤24 hours postoperatively (range 2-72 hours). Mean time to first feed was significantly lower in the early feeding group, but not significantly lower for the mean time to full feeds and mean hospital stay. Bowel obstruction and anastomotic breakdown were classed as major complications. There was no significant difference in their occurrence in both groups. Although the studies identified are few and heterogeneous, they demonstrate that there is no clear advantage of keeping children "nil by mouth" and no clear disadvantage of providing early enteral nutrition following elective gastrointestinal surgery. Larger randomized controlled trials are required to assess the true impact on postoperative complications, health care associated costs, and to investigate patient-reported outcome measures.