Length Of Common Channel Research Articles

A Longer Biliopancreatic Limb and Shorter Common Channel Enhance Weight Loss But May Have Harmful Effects in Mouse Models of Roux-en-Y Gastric Bypass.

RYGB consists of the Roux limb (RL), the biliopancreatic limb (BPL), and the common channel (CC). There is no consensus on the optimal limb lengths. Using a mouse model of RYGB, 30 diet-induced obese mice were divided into two groups with varying BPL and CC lengths: a standard BPL with a long CC (RYGB S) and a long BPL with a short CC (RYGB L). Additionally, 9 age-matched, lean control mice (LC) were also included in this study. RYGB S had limb lengths of RL = 17%, BPL = 24%, and CC = 59%. RYGB L had limb lengths of RL = 17%, BPL = 32%, and CC = 51%. RYGB S and RYGB L had 67% and 40% survival, respectively. Mortality in RYGB L included more instances where the cause of death was not apparent. RYGB L demonstrated greater weight loss, lower energy expenditure, and lower heart mass as compared to RYGB S. Both RYGB groups had lower epidydimal fat mass, spleen mass, and bone mineral density compared to LC. RYGB L had a lower heart mass than RYGB S and LC. While the relative abundance of Eubacterium was lower in RYGB L than in RYGB S, no other gut microbiota differences were observed. A longer BPL with a shorter CC induces greater weight loss but may lead to adverse effects, including lower heart mass, reduced bone density, and deaths with unclear causes.

The effect of surgical reconstruction on bladder function in cloacal malformation: A study of urodynamics

Girls with cloacal malformation are at risk of bladder dysfunction, with nearly 90% exhibiting some degree of dysfunction. Surgical dissection, particularly with total urogenital mobilization (TUM), has been hypothesized as a cause of worsening bladder function despite this population commonly having associated vertebral and spinal cord abnormalities that may also explain bladder dysfunction. More recently there has been great effort to select the appropriate surgical technique for cloacal repair in each patient in order to minimize dissection and potential damage to the bladder. We aimed to evaluate the effect of surgical cloacal repair on bladder function based on pre and post-surgery urodynamics (UDS) testing. A prospectively collected database of patients with anorectal malformation at a single center was queried for girls with cloacal malformations who had undergone surgical repair from 2015 to 2022. It is our current protocol to perform UDS before and after cloacal repair. Only patients who completed both pre and post-surgery UDS were included. UDS were evaluated and classified using the UMPIRE protocol. A total of 48 patients were included in the cohort. The majority of patients (79.2%) had stable or improved UDS post-op leaving 10 patients (20.8%) who had worsening UDS. Long common channel (≥3cm) was the only factor significantly associated with worsening UDS. (p=0.03) Nearly 30% (n=8) of those undergoing UGS had worse post-op UDS compared to 9.5% (n=2) with TUM. All patients who worsened UDS initially had safe UDS that changed to intermediate, except for one who worsened to hostile in the setting of significant social challenges and non-compliance. Only common channel length was predictive of worsening UDS, while the type of surgical approach and spine status were not. While the overall risk of worsening UDS after TUM is only 9.5%, patients with normal spines undergoing TUM had the lowest risk, seen in only one in 15 patients (6.6%). Common channel length was the most significant predictor of worsening UDS, while spine status and surgical technique (TUM vs UGS) did not significantly impact this finding. By following this established surgical protocol based on common channel and urethral lengths, is rare for the surgical cloacal repair to result in worsening post-op UDS, particularly in those undergoing TUM for short common channel and normal spine.

Utility of Contrast-Enhanced Harmonic Endoscopic Ultrasonography to Diagnose Pancreaticobiliary Maljunction.

Detection of a common channel outside the duodenal wall is important in diagnosing pancreaticobiliary maljunction (PBM). The present study evaluated the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) in diagnosing PBM. This single-center retrospective study enrolled 45 patients who were diagnosed with PBM or high confluence of pancreatobiliary ducts (HCPBD) between January 2007 and December 2021. The diagnostic sensitivities of contrast-enhanced computed tomography (CE-CT), magnetic resonance imaging (MRI), and CH-EUS for diagnosing PBM were analyzed. Imaging findings were evaluated by two reviewers blinded to the clinicopathological results. Based on diagnostic criteria, 33 patients were diagnosed with PBM and 12 with HCPBD. Compared with the patients with HCPBD, those with PBM had significantly longer common channel (12.5mm vs. 8.1mm, P = 0.018) and common bile duct (13.0mm vs. 8.6mm, P = 0.049) lengths. The κ-coefficients for differentiating PBM and HCPBD were 0.871 between CE-CT and MRI, 0.330 between CE-CT and CH-EUS, and 0.611 between MRI and CH-EUS. The diagnostic sensitivity of CH-EUS (95.2%) was higher than that of CE-CT (83.3%) and MRI (82.8%), although the differences were not statistically significant. CH-EUS may be useful for the diagnosis of PBM.

Revisional surgery for malnutrition after SADI-S: prevalence, indications, techniques and outcomes.

SADIS with short common limb (< 250cm) is a malabsorptive operation. Reoperation is advised in patients requiring admission for severe malnutrition. Elongation of the common channel is the preferred revisional technique Introduction: Single-Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy (SADI-S) is a modification of the duodenal switch. Initial common channel's length was 200, and after malnutrition was detected in some patients, it was elongated to 250 or 300cm. The present study analyzes presentation and treatment of malnutrition after SADI-S. Three hundred and thirty-three consecutive patients undergoing SADI-S between May 2007 and February 2019 were included. The common limb length was 200cm in 50 cases, 250cm in 211, 300 in 71 and 350 in 1. Thirty-one patients were admitted for severe hypoalbuminemia and 17 patients were submitted to revisional surgery, and constitute the series of our study. Mean weight before reoperation was 57kg and mean body mass index (BMI) was 21kg/m2. Mean number of daily bowel movements was 5,6. Mean time to reoperation was 56months. The limb was found shorter than expected in 6 cases. Revisional surgery was conversion into a Roux en Y duodenal switch in 3 cases, elongation of the common limb in 11 patients, duodeno-duodenostomy in 1 and duodeno-jejunostomy to the first jejunal loop in 2. Mean weight regain was 14kg, and mean final BMI 26kg/m2. Daily bowel movements were reduced to 1,3. Factors related to hypoalbuminemia were hypertension, poor-controlled diabetes, shorter common limb and liver-test alterations. SADI-S is expected to be less malabsorptive than previous biliopancreatic diversions. However, caution must be taken with certain patients to avoid postoperative malnutrition. Adequate follow up with long-term supplementation is required.

Bladder Management and Continence in Girls With Cloacal Malformation After 3 Years of Age

BackgroundMultiple factors impact ability to achieve urinary continence in cloacal malformation including common channel (CC) and urethral length and presence of spinal cord abnormalities. Few publications describe continence rates and bladder management in this population. We evaluated our cohort of patients with cloacal malformation to describe the bladder management and continence outcomes. MethodsWe reviewed a prospectively collected database of patients with cloacal malformation managed at our institution. We included girls ≥3 years (y) of age and evaluated their bladder management methods and continence. Dryness was defined as <1 daytime accident per week. Incontinent diversions with both vesicostomy and enterovesicostomy were considered wet. ResultsA total of 152 patients were included. Overall, 93 (61.2%) are dry. Nearly half (47%) voided via urethra, 65% of whom were dry. Twenty patients (13.1%) had incontinent diversions. Over 40% of the cohort performed clean intermittent catheterization (CIC), approximately half via urethra and half via abdominal channel. Over 80% of those performing CIC were dry. In total, 12.5% (n = 19) required bladder augmentation (BA). CC length was not associated with dryness (p = 0.076), need for CIC (p = 0.253), or need for abdominal channel (p = 0.497). The presence of a spinal cord abnormality was associated with need for CIC (p = 0.0117) and normal spine associated with ability to void and be dry (p = 0.004) ConclusionsIn girls ≥ 3 y of age with cloacal malformation, 61.2% are dry, 65% by voiding via urethra and 82% with CIC. 12.5% require BA. Further investigation is needed to determine anatomic findings associated with urinary outcomes. Level of EvidenceIV.

Single Anastomosis Duodenoileostomy with Sleeve: A Comprehensive Review of Anatomy, Surgical Technique, and Outcomes.

Single anastomosis duodenoileal bypass with sleeve (SADI-S) is a recently endorsed metabolic and bariatric surgery (MBS) procedure in the US. Despite its favorable characteristics, the utilization of SADI-S remains limited, accounting for a mere 0.25% of all MBS procedures performed. This review aims to offer an updated examination of the technique, while also presenting the safety and outcomes associated with SADI-S on both the short and long term. The safety of SADI-S is well-established, with short-term complication rates as low as 2.6%. A common channel length of 300cm has consistently shown a lower incidence of malabsorption complications compared to shorter lengths. Bile reflux after SADI-S is relatively rare with an incidence of only 1.23%. SADI-S demonstrated sustained total weight loss (%TWL) at 5years (37%) and 10years (34%) postoperatively. Resolution of weight-related medical conditions was also significant after SADI-S, with remission rates of diabetes mellitus as high as 86.6% with over 5years of follow-up. SADI-S is a safe and effective MBS procedure that has shown impressive and sustainable results in terms of weight loss and improvement in obesity-related medical conditions. Careful limb length selection is essential in minimizing the risk of nutritional deficiencies. SADI-S holds great promise as a valuable option for individuals seeking effective weight loss and improvement in associated health conditions.

One Anastomosis Transit Bipartition (OATB): Rational and Mid-term Outcomes.

The "One-anastomosis transit bipartition" (OATB) is a promising emerging technique in the metabolic syndrome treatment. To demonstrate the results achieved with OATB in the first 5years after surgery. Cross-sectional, retrospective study, with individuals undergoing primary OATB. Individuals included in the study were: ≥ 18years, BMI ≥ 35kg/m2; and excluded smoking habits, drug dependence, inflammatory bowel diseases. The data analyzed demographic, anthropometric, surgical, clinical, and nutritional. Sixty eight participants, 75% women, average age 45.5years and BMI 41kg/m2. Associated diseases: osteoarthritis (52.9%), hypertension (48.5%) and type 2 diabetes mellitus-T2DM (39.7%). All underwent laparoscopy, without conversions. Average operative time is 122.6 ± 31.7min, and hospital stay is 2.2 ± 0.8days. The common channel length 27 and 41 patients with 250cm and 300cm respectively. We registered no intraoperative complications, 2 (2.9%) early complications, and 14 (20.6%) late complications. In the first 6months, 94.7% (250cm) and 88.9% (300cm) of the patients no longer used medication for T2DM, with no statistical difference between the two groups. The incidence of nutritional disorders at any time during follow-up: hypovitaminosis D (14.7%), folate hypovitaminosis (14.7%), elevated PTH (7.4%), hypoproteinemia (5.9%) and anemia (5.9%). We found no statistically significant difference between 250 and 300cm common channel groups. We conclude that OATB is a safe and effective technique, demonstrating good control of T2DM and metabolic syndrome. There is a requirement to treat previous nutritional deficits. We need more long-term evidence and comparison to other surgical techniques.

How we select our surgical approach for cloacal reconstruction

During cloacal reconstruction, we consider both common channel (CC) and urethral length when deciding between total urogenital mobilization (TUM) and a urogenital separation (UGS). Our concern about TUM in the case of a short urethra is resultant bladder neck incompetence, while conversion to UGS after completing the TUM dissection may result in urethral injury. Use of an interposition flap harvested from the ischiorectal fossa is another measure we use to prevent potential complications.

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch.

Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications. A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared. A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7months in the pre-TBL group and 6.7months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3months (4.2g/dL vs 3.5g/dL, p < 0.001), 6months (4.1g/dL vs 3.6g/dL, p < 0.001), and 12months (4.2g/dL vs 3.8g/dL, p = 0.023) postoperatively when compared to the pre-TBL group. Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Remission of Type II Diabetes Mellitus after Duodenal Switch: the Contribution of Common Channel Length

IntroductionThe role of the common channel length in duodenal switch (DS) on remission of type II diabetes mellitus (DM), when stratifying patients based on diabetes severity, is not well understood.MethodsWe retrospectively reviewed 341 consecutive patients with DM undergoing DS with one of three different common channel (CC) lengths (100 cm, 150 cm, and 200 cm), each with a fixed 300 cm alimentary limb (AL). Patients were stratified by insulin dependence (IDDM) versus non-insulin dependent diabetes (NIDDM). Data was collected at one year and at the last available follow-up.ResultsThe NIDDM group had a similar average HbA1c at last follow-up for each of the CC lengths. However, the IDDM group had lower average HbA1c with shorter CC lengths (100 cm = 5.4%, 150 cm = 6%, 200 cm = 6.4%, p < 0.05). Shorter CC lengths resulted in a greater proportion of patients achieving remission in the IDDM group (66%, 50%, 32% in the 100 cm, 150 cm, and 200 cm CC, respectively, p < 0.01). Improvements in HbA1c were independent of weight loss and average DiaRem scores were similar between CC lengths. Rates of nutritional deficiencies were higher in shorter common channel lengths. Revision for malnutrition was similar between common channel lengths (100 cm group: 3.7%; 150 cm group: 1.8%; 200 cm group: 0%, p = NS).ConclusionsWhen the AL is fixed, shortening CC lengths results in improved glycemic control and remission of DM in patients with the need for insulin preoperatively. Milder forms of DM are treated well with any of the CC lengths.Graphical

Clinical presentations and outcomes of pancreaticobiliary maljunction in different pediatric age groups

BackgroundPancreaticobiliary maljunction (PBM) is a congenital defect, with risk of developing various pancreaticobiliary and hepatic complications. The presentations of PBM in children and adults are believed to be different, but studies on PBM children of different age groups are limited. This study was to evaluate clinicopathologic characteristics and outcomes in PBM children of different ages.MethodsA total of 166 pediatric patients with PBM were reviewed retrospectively. Clinicopathological, imaging, laboratory, surgical, and follow-up data were collected and analyzed. The patients were divided into three age groups, namely, group A (< 1 year, n = 31), group B (1–3 years, n = 63), and group C (> 3 years, n = 72).ResultsThe major clinical manifestation was jaundice in group A and abdominal pain and vomiting in groups B and C. Acute pancreatitis was more often seen in group C than group A. The length of common channel was significantly longer in group C than group A, while the maximum diameter of common bile duct in group C was smaller than that in group A. Cholangitis and cholecystitis were more commonly performed in groups B and C, while hepatic fibrosis in group A. Whether preoperatively or postoperatively, group C was more likely to have elevated serum amylase, while groups A and B were more likely to present with abnormal liver function indicators, including the increase of aspartate transaminase, alanine transaminase, and gamma-glutamyl transpeptidase.ConclusionPresentation of PBM varies among different pediatric age groups, thus suggesting that targeted management should be carried out according to these differences.

Long-term urological outcome of cloaca patients with multidisciplinary management.

Urological management of Cloacal Malformation (CM) focuses on preserving renal function and continence. Study aim was to analyze urinary and intestinal outcomes in CM patients, considering the length of common channel (CC) and presence of occult spinal dysraphism (OSD). Retrospective review of CM treated at our institution by a multidisciplinary team from 1999 to 2020. Patients with follow-up < 2.5years were excluded. Length of CC, renal function, urinary and bowel outcomes, presence of associated anomalies (especially OSD) were evaluated. Twenty patients were included, median age at follow-up: 8years (4-15). A long CC > 3cm was described in 11 (55%). Chronic kidney disease was found in 3 patients. Urinary continence was achieved in 8/20 patients, dryness (with intermittent catheterization) in 9/20. Fecal continence was obtained in 3/20, cleanliness in 14 (under bowel regimen). OSD was present in 10 patients (higher prevalence in long-CC, 73%). Among OSD, 1 patient reached fecal continence, 7 were clean; 2 achieved urinary continence, while 6 were dry. Length of CC and OSD may affect urinary and fecal continence. An early counseling can improve outcome at long-term follow-up. Multidisciplinary management with patient centralization in high grade institutions is recommended to achieve better results.

The accuracy of ultrasound in common channel length measurement compared with intraoperative endoscopy in persistent cloaca patient

BackgroundsIn persistent cloaca (PC), the vagina, urethra, and rectum are fused together in the pelvis, creating a common channel (CC). CC length, short or long will determine the definitive surgery and can be evaluated preoperatively using radiological studies. But to our knowledge currently, there were limited studies discussing the use of ultrasound (US). The aim of this study is to evaluate the accuracy of ultrasound in CC length measurement compared with intraoperative endoscopy. MethodsThis study was analytics observational with cross-sectional design in 16 patients with cloaca. The sample was obtained by consecutive sampling from January 2015 until April 2022 in Dr. Hasan Sadikin General Hospital. CC length was measured preoperatively using US and intraoperatively using endoscopy. ResultsFrom 16 PC patients, short CC (<3 cm) measured with both US and endoscopy were 12 patients (100%), and short CC measured by US with long CC (>3 cm) measured by intraoperative endoscopy were 3 patients (75%). Long CC measured by both US and endoscopy was found in 1 patient (25%). Based on the diagnostic test result, ultrasound sensitivity was 99%, specificity was 25%, positive predictive value (PPV) was 100%, negative predictive value (NPV) was 25%, and accuracy was 75%. ConclusionsUltrasound has a high sensitivity in common channel length measurement. Level of confidenceLevel II

Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass.

Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL). The small bowel length in humans is variable from as short as < 400cm to as long as > 1000cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.

A109 Using Total Bowel Length Measurements to Calculate Common Channel Length Reduces Reoperations and Long-Term Complication Rates after Single-Anastomosis Duodenal Switch

A109 Using Total Bowel Length Measurements to Calculate Common Channel Length Reduces Reoperations and Long-Term Complication Rates after Single-Anastomosis Duodenal Switch

Partial urogenital mobilization in cloacal malformation: is it a viable option?

Total Urogenital Mobilization (TUM) has been the standard surgical approach for the urogenital complex in Cloacal Malformations (CM) since its inception in 1997. Partial Urogenital Mobilization (PUM) in CM remains an under-utilized or under-reported option. The main anatomical difference between TUM and PUM is the division of the pubo-urethral ligaments. We explored the feasibility of PUM in a select subset of our patients with CM and report early outcomes. We retrospectively reviewed prospectively collected data of all our CM patients who had primary reconstruction at our centre from 2012 to 2020. We included in our review the patients who underwent PUM. Mullerian abnormalities, spinal cord involvement, common channel length (CC), urethral length (UL), surgical reconstruction, and outcomes including urinary continence, recurrent UTI, ultrasound and preoperative DMSA/MAG3, cystovaginoscopy post-reconstruction, and post-void residuals were noted. Fifty-three patients had primary reconstruction, and of these, eleven had a common channel less than 3cm. Of the eleven, only one underwent TUM. In the PUM group, two underwent filum untethering (20%). Mullerian duplication was noted in 5 patients (50%). The median CC length=1.6cm (range=1.5cm-2.7cm), and median UL=1.5cm (range=1.5cm-2.5cm). Follow-up ranged from 9 to 134months (median=63months). Post-reconstruction all had a separate urethral and vaginal opening on examination and cysto-vaginoscopy. The continence outcomes are summarized in Fig.1. Although TUM is the most common solution for the urogenital complex in CM, a subset would be suitable for PUM, and this option is under-utilized or under-reported in literature. We presume that many who had TUM probably only needed a PUM, and therefore could report better outcomes from a bladder function aspect. It is important to differentiate the two, and outcomes should be appropriately categorized. Our default approach is a PUM in all CM with less than 3cm common channel. Only the lateral and posterior aspects of the urogenital complex are mobilized and if the urethra did not reach a satisfactory level for easy intermittent catheterization, then we proceed to a TUM dividing the pubo-urethral ligaments. PUM avoids the potential complications related to dividing the pubo-urethral ligament in TUM. It may also avoid the need for CIC which is encountered in patients who undergo TUM. PUM is a viable alternative in cloacal malformations with good outcomes in those with a common channel under 3cm. This of course requires appropriate patient selection and accurate categorization of interventions to understand the true outcomes.

A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience

Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs. 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying. We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate=common channel [CC] <3-cm, severe=CC≥3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy). Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated. Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function. Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively.

Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study.

Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated. We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed. We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group. Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50kg/m2.

Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50kg/m2. We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI 335kg/m2 and < 50kg/m2) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie. A retrospective review was performed on patients with a BMI < 50mg/k2 who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate. Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20cm and 154 ± 18cm, respectively. Preoperative BMI was 44.9 ± 2.3kg/m2 and follow-up was 2.7 ± 1.4years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency. BPD-DS may be considered in patients with BMI < 50kg/m2 with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

45 years’ experience with early childhood anatomical technique of feminising genitoplasty for 46 XX Congenital Adrenal Hyperplasia –observations of vaginal introital anatomy and its relationship to the perineal body

In Manchester, feminising genitoplasty is offered to children with 46XX Congenital Adrenal Hyperplasia (CAH) when there is a single perineal opening and/or enlarged clitoris. Our aims are to describe the anatomical reconstructive technique and present long-term outcomes. Our hypothesis is that 'the common channel (CC) length and distance to the vagina from perineal skin is mostly due to virilisation and hypertrophy of perineal tissue over the almost normally positioned vaginal introitus (V-I) in relation to the perineal body (PB)'. METHOD AND RESULTS: This is a retrospective notes review of all consecutive 46XX CAH operations from 1976 to December 2021. 99 patients, who had feminising genitoplasty and being followed-up, were included. 15 patients who were lost to follow up were excluded. Median age at surgery was 15 months. In 91, midline division of the labia majora, spongiosum, bulbo-spongiosus muscle (BSM) and CC down to PB was performed. This was sufficient to expose the V-I at the same level or within 5mm depth of PB in 88. In 78V-I was adequate taking 10/12fr dilator (Type 1). In 10, CC resembled a male urethra and V-I was narrow (Type 2), requiring widening by 5-10mm incision at 6 o'clock position. Dartos of labia majora was attached to BSM to reduce the distance to V-I from perineal skin and the gap was lined with inner foreskin to create a vestibule. Out of 70 who were post-pubertal, 75% (53/70) had adequate calibre vaginal openings. 5 had introitoplasty and 2 had dilatation under anaesthesia. 10 needed self dilators only. 29 patients, of one of the three surgeons, had measurements of clitoris, CC, urethra and vagina. A hymen was found in 86% (25/29). There was significant strong, inverse correlation between the CC length and the urethral length (r=-0.708, p<0.001, n=27) but not between CC and vaginal lengths. After adjusting for age, the urethral length of Type 2 patients was 3.825mm shorter than those of Type 1 (p=0.017). CONCLUSION: Our data show that 'high' confluence is mostly due to virilisation of genitalia; and the anatomical technique of reversing the fusion of the urethral folds, spongiosum and bulbo-spongiosus muscle could be performed with all degrees of virilisation with success in early childhood with no need of local flaps or mobilisation of the urethro-vaginal complex. About 10% require surgery to treat narrowing of vaginal opening post puberty.