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Golubkova A, Hunter CJ. Updates and recommendations on the surgical management of NEC. Semin Perinatol 2023; 47:151698. [PMID: 36572621 DOI: 10.1016/j.semperi.2022.151698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature.
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Human MJ, Tshifularo N, Mabitsela M. Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial. Pediatr Surg Int 2022; 38:1291-1296. [PMID: 35771234 PMCID: PMC9355919 DOI: 10.1007/s00383-022-05155-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain. METHODS Patients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019-2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the "drain" (D) and "no drain" (ND) groups. RESULTS Thirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the "D" group was 18% and 35% in the "ND" group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups. CONCLUSION From our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications. TRIAL REGISTRATION NUMBER SMUREC/M/15/2019: PG.
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Affiliation(s)
- M J Human
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa.
| | - N Tshifularo
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa
| | - M Mabitsela
- Department of Paediatric Surgery, Sefako Makgatho Health Sciences University, Dr George Mukhari Academic Hospital, Molotlegi Road, Ga-Rankuwa, Pretoria, 0208, South Africa
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Reeves N, Vogel I, Ghoroghi A, Ansell J, Cornish J, Torkington J. Peritoneal cytokines as a predictor of colorectal anastomotic leaks on postoperative day 1: a systematic review and meta-analysis. Tech Coloproctol 2021; 26:117-125. [PMID: 34817744 DOI: 10.1007/s10151-021-02548-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/11/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a major complication of colorectal surgery resulting in morbidity, mortality and poorer quality of life. The early diagnosis of AL is challenging due to the poor positive predictive value of tests available and reliance on clinical presentation which may be delayed. The aim of this systematic review was to assess the applicability of peritoneal cytokine levels as an early predictive test of AL in postoperative colorectal cancer patients. METHODS A comprehensive literature search was performed from inception to January 2021, in MEDLINE and EMBASE databases using MeSH and non-MeSH terms in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies evaluating peritoneal cytokines in the context of AL were included in this review. RESULTS Two hundred ninety-two abstracts were screened, 30 full manuscripts evaluated, and 12 prospective studies were included. There were 8 peritoneal cytokines evaluated (interleukin [IL]-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor [VEGF], tumour necrosis factor alpha [TNF alpha] and matrix metalloproteinase [MMP]2 and MMP9) between AL and non-AL groups on postoperative day 1. Those that included IL-6 (7 studies), IL-10 (4 studies), TNF alpha (6 studies) and MMP9 (2 studies) were included in the meta-analysis. IL-10 was the only cytokine in the meta-analysis that was significantly (p < 0.05) raised in drain fluid on postoperative day 1 in AL patients. CONCLUSIONS Peritoneal IL-10 was significantly raised on postoperative day 1 in patients who subsequently developed AL. This may be a useful early predictor of AL and aid in an earlier diagnosis for postoperative colorectal patients. The range of cytokines investigated within the literature is limited and from heterogeneous studies which suggests more research is needed.
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Lure AC, Du X, Black EW, Irons R, Lemas DJ, Taylor JA, Lavilla O, de la Cruz D, Neu J. Using machine learning analysis to assist in differentiating between necrotizing enterocolitis and spontaneous intestinal perforation: A novel predictive analytic tool. J Pediatr Surg 2021; 56:1703-1710. [PMID: 33342603 DOI: 10.1016/j.jpedsurg.2020.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are devastating diseases in preterm neonates, often requiring surgical treatment. Previous studies evaluated outcomes in peritoneal drain placement versus laparotomy, but the accuracy of the presumptive diagnosis remains unknown without bowel visualization. Predictive analytics provide the opportunity to determine the etiology of perforation and guide surgical decision making. The purpose of this investigation was to build and evaluate machine learning models to differentiate NEC and SIP. METHODS Neonates who underwent drain placement or laparotomy NEC or SIP were identified and grouped definitively via bowel visualization. Patient characteristics were analyzed using machine learning methodologies, which were optimized through areas under the receiver operating characteristic curve (AUROC). The model was further evaluated using a validation cohort. RESULTS 40 patients were identified. A random forest model achieved 98% AUROC while a ridge logistic regression model reached 92% AUROC in differentiating diseases. When applying the trained random forest model to the validation cohort, outcomes were correctly predicted. CONCLUSIONS This study supports the feasibility of using a novel machine learning model to differentiate between NEC and SIP prior to any intended surgical interventions. LEVEL OF EVIDENCE level II TYPE OF STUDY: Clinical Research Paper.
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Affiliation(s)
- Allison C Lure
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States.
| | - Xinsong Du
- University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Erik W Black
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States; University of Florida College of Education, 1221 SW 5th Ave, Gainesville, FL 32601, United States
| | - Raechel Irons
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Dominick J Lemas
- University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Janice A Taylor
- University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Orlyn Lavilla
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Diomel de la Cruz
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Josef Neu
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
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Fatemizadeh R, Mandal S, Gollins L, Shah S, Premkumar M, Hair A. Incidence of spontaneous intestinal perforations exceeds necrotizing enterocolitis in extremely low birth weight infants fed an exclusive human milk-based diet: A single center experience. J Pediatr Surg 2021; 56:1051-1056. [PMID: 33092814 DOI: 10.1016/j.jpedsurg.2020.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/19/2020] [Accepted: 09/17/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are complications of extremely low birth weight (ELBW, ≤1000 g) infants. ELBW infants at Texas Children's Hospital receive an exclusive human milk-based diet, which has been associated with a reduction of NEC. OBJECTIVES 1) Assess incidence of SIP and NEC (Stage II or greater) in ELBW infants receiving 100% human milk-based diet, 2) Describe mortality rates of ELBW infants with SIP and NEC. METHODS Prospective single-center observational cohort study of ELBW infants born between 2010 and 2014 with SIP or NEC (exclusion: congenital anomalies and death within 48 h). RESULTS Of 379 ELBW infants, 345 were eligible. Of these, 28 (8.1%) had SIP and 8 (2.3%) had NEC (medical n = 1, surgical n = 7). SIP infant mortality was 32% (n = 9) compared to 63% (n = 5) for NEC patients. Of SIP infants with PD (n = 25), 52% required subsequent exploratory laparotomy (LAP). Of NEC infants with peritoneal drainage (PD) (n = 2), both required subsequent LAP. CONCLUSION Using an exclusive human milk-based diet, the incidence of SIP exceeds NEC in ELBW infants at our institution. This shows a changing trend in the incidence of these two diagnoses in the era of human milk, as NEC had previously been more prevalent in ELBW infants. More than half of infants who initially received PD later required LAP. There were no differences in survival outcomes in both SIP and NEC groups based on surgical management.
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Affiliation(s)
| | | | - Laura Gollins
- Clinical Nutrition Services, Texas Children's Hospital, Houston, TX, USA
| | - Sohail Shah
- Department of Pediatric Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Amy Hair
- Department of Neonatology, Baylor College of Medicine, Houston, TX, USA.
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Ahle S, Badru F, Damle R, Osei H, Munoz-Abraham AS, Bajinting A, Barbian ME, Bhatia AM, Gingalewski C, Greenspon J, Hamilton N, Stitelman D, Strand M, Warner BW, Villalona GA. Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy. J Pediatr Surg 2020; 55:1270-1275. [PMID: 31383579 DOI: 10.1016/j.jpedsurg.2019.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of our study was to compare outcomes of infants with spontaneous intestinal perforation (SIP) treated with primary peritoneal drain versus primary laparotomy. METHODS We performed a multi-institution retrospective review of infants with diagnosis of SIP from 2012 to 2016. Clinical characteristics and outcomes were compared between infants treated with primary peritoneal drain vs infants treated with laparotomy. RESULTS We identified 171 patients treated for SIP (drain n = 110 vs. laparotomy n = 61). There were no differences in maternal or prenatal characteristics. There were no clinically significant differences in vital signs, white blood cell or platelet measures, up to 48 h after intervention. Patients who were treated primarily with a drain were more premature (24.9 vs. 27.2 weeks, p < 0.001) and had lower median birth weight (710 g vs. 896 g, p < 0.001). No significant differences were found in complications, time to full feeds, length of stay (LOS) or mortality between the groups. Primary laparotomy group had more procedures (median number 1 vs. 2, p = 0.002). There were 32 (29%) primary drain failures whereby a laparotomy was ultimately needed. CONCLUSIONS SIP treated with primary drain is successful in the majority of patients with no significant differences in outcomes when compared to laparotomy with stoma. THE LEVEL OF EVIDENCE III.
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Affiliation(s)
- Samantha Ahle
- Section of Pediatric Surgery, Yale University School of Medicine/Yale-New haven Hospital, New Haven, CT.
| | - Faidah Badru
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO; Saint Louis University School of Medicine, Saint Louis, MO
| | - Rachelle Damle
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
| | - Hector Osei
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
| | - Armando Salim Munoz-Abraham
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
| | - Adam Bajinting
- Section of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR
| | | | - Amina M Bhatia
- Section of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA
| | - Cindy Gingalewski
- Section of Pediatric Surgery, Oregon Health and Science University, Portland, OR
| | - Jose Greenspon
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
| | - Nicholas Hamilton
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - David Stitelman
- Section of Pediatric Surgery, Yale University School of Medicine/Yale-New haven Hospital, New Haven, CT
| | - Marya Strand
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
| | - Brad W Warner
- Division of Pediatric Surgery, Washington University School of Medicine/Saint Louis Children's Hospital, St. Louis, MO
| | - Gustavo A Villalona
- Section of Pediatric Surgery, Saint Louis University/Cardinal Glennon Children's Medical Center, St. Louis, MO
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Abstract
Necrotising enterocolitis (NEC) is a neonatal surgical emergency. At its early stages, the management of NEC is largely medical using broad-spectrum antibiotics, gut rest and total parental nutrition. The only absolute indication for surgery is an intra-abdominal perforation. There are several relative indications for surgery based on clinical, biochemical and radiological parameters. Once the decision to intervene is made, several approaches may be taken. Peritoneal lavage can be used as a salvage procedure or definitive management in some cases. The most common approach taken is bowel resection with enterostomy formation. There is a role for primary anastomosis of bowel in limited NEC. In severe, multi-focal NEC a high diverting jejunostomy or "clip and drop technique" can be used. Laparoscopy has a limited role and is not widespread. The surgical complications of NEC include stoma related morbidity, anastomotic leak/stricture and short-bowel syndrome. Long-term data on neurodevelopmental outcomes is sparse but the present literature is suggestive of a negative impact in cases of surgically managed NEC.
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Bevan J, Penn LA, Mitchell ARJ. Permanent catheter drainage system for palliation of diuretic-resistant cardiac ascites. ESC Heart Fail 2015; 3:60-62. [PMID: 27774268 PMCID: PMC5064730 DOI: 10.1002/ehf2.12074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 10/12/2015] [Indexed: 11/08/2022] Open
Abstract
We report the case of a 69-year-old man with dilated cardiomyopathy treated with a permanent catheter drainage system for diuretic resistant cardiac ascites. At 1 year follow-up, the patient had no heart failure related hospitalisations, displayed improved quality of life measures and had incurred no complications related to the catheter. Permanent tunnelled catheters are widely used to treat malignant ascites but may also be considered for palliation of cardiac ascites.
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Affiliation(s)
- Jonathan Bevan
- Department of Cardiology Jersey General Hospital Gloucester Street St Helier Jersey
| | - Lee-Anne Penn
- Department of Cardiology Jersey General Hospital Gloucester Street St Helier Jersey
| | - Andrew R J Mitchell
- Department of Cardiology Jersey General Hospital Gloucester Street St Helier Jersey
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Beek MA, Jansen TS, Raats JW, Twiss ELL, Gobardhan PD, van Rhede van der Kloot EJH. The utility of peritoneal drains in patients with perforated appendicitis. Springerplus 2015. [PMID: 26217548 PMCID: PMC4512985 DOI: 10.1186/s40064-015-1154-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Intra-abdominal abscesses are the most common complication after perforated appendicitis and remain a significant problem ranging in incidence from 14 to 18%. Drainage following appendectomy is usually determined by whether the underlying appendicitis is simple or complicated and largely determined by the surgeons’ belief, based on expertise or personal opinion. In this report we discuss the results of patients diagnosed with peritoneal drainage, treated with or without a peritoneal drain. Patients and methods A retrospective study of patients diagnosed with perforated appendicitis having surgery was performed. Patients diagnosed with perforated appendicitis treated with a peritoneal drain and patients treated without a peritoneal drain. Both groups were evaluated in terms of complications: intra-abdominal abscess, re-intervention, readmission and duration of hospital stay. Results 199 patients diagnosed with perforated appendicitis underwent appendectomy. 120 patients were treated without a peritoneal drain and 79 patients with a peritoneal drain. Thirty-one (26%) patients from the group without a peritoneal drain had a re-intervention compared to 9 (11%) in the group with a peritoneal drain (p = 0.013). Overall complications and readmission were also significantly lower in patients treated with a peritoneal drain. Conclusion A peritoneal drain seems to reduce overall complication rate, re-intervention rate and readmission rate in patients treated with perforated appendicitis.
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Affiliation(s)
- Martinus A Beek
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Tim S Jansen
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Jelle W Raats
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Eric L L Twiss
- Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
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