Management of lower urinary tract fibroepithelial polyps in children

Introduction Fibroepithelial polyps (FEP) of the lower urinary tract are relatively common in adults but rare in children, with fewer than 250 cases reported in the literature to date. Objective The aim of this study was to address the experience of FEP management in children. Study design A retrospective multicenter review was undertaken in children with defined FEP of the lower urinary tract managed between 2008 and 2018. The data at 18 pediatric surgery centers were collected. Their demographic, radiological, surgical, and pathological information were reviewed. Results A total of 33 children (26 boys; 7 girls) were treated for FEP of the lower urinary tract at 13 centers. The most common presentation was urinary outflow as hematuria (41%), acute urinary retention (25%), dysuria (19%), or urinary infections (28%). A prenatal diagnosis was made for three patients with hydronephrosis. Almost all of the children (94%) underwent ultrasound imaging of the urinary tract as the first diagnostic examination, 23 (70%) of them also either had an MRI (15%), cystourethrography (25%), computerized tomography (6%), or cystoscopy (45%). Two of these children (6%) had a biopsy prior to the surgery. The median preoperative delay was 7.52 (range: 1–48) months. Most of the patients were treated endoscopically, although four (12.1%) had open surgery and two (6.1%) had an additional incision for specimen extraction. The median hospital stay was 1.5 (range: 1–10) days. There were no recurrences and no complications after a median follow-up of 13 (range: 1–34) months. Discussion The main limitation of our study is the retrospective design, although it is the largest one for this pathology. Conclusion This series supports sonography as the most suitable diagnosis tool before endoscopy to confirm the diagnosis and to perform the resection for most FEP in children. This report confirms the recognized benign nature in the absence of recurrences

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Etude de la paroi intestinale dans un modèle murin d'interruption intestinale : rôles des cellules du SNE et des cellules neuroendocrines

Aim of the studyIntestinal atresia is a rare congenital affection with postoperative motility disorders, leading sometimes to death. Previous related studies mainly focused on enteric nervous system (ENS) alterations as it was identified to cause abnormal peristalsis. The aim of the study was to expertise the underlying pathological conditions of intestinal atresia using a global approach, before focusing on ENS and neuroendocrine cells in order to precise the presumptive involvement of the different layers of the intestinal wall.MethodsPreliminary transcriptomic approach was elected to screen global gene expression involved in intestinal development and atresia-linked disorders in the rat model previously described by our team. Rat embryos were assigned to atretic group and controls embryos at different stages of development ED15, ED17, ED19 and ED21. Two successive intestine samples of 1 cm were harvested in the proximal segment and in the distal one. The pattern of gene expression was further assessed by immunohistochemistry, electron microscopy and RT-qPCR. Main resultsA physiological decrease in gene expression for enteric nervous system markers and an increase for neuroendocrine and epithelial system was observed on controls from stages ED15 to ED21. Regarding affected embryos, structural modifications concerned the proximal segment with increased muscular layer and a significant disruption including global accelerated maturation was observed in the proximal segment with increased gene expression of neuroendocrine system. Distal segment was comparable to controls for the two systems. Important modifications were noted concerning the epithelial system with consequent abnormalities of the gut barrier and anti infectious functions.ConclusionsFetal intestinal obstruction results in a disrupted gut development predominant in the proximal segment. The distal segment and the ENS were poorly concerned by theses changes. Neuroendocrine and epithelial cells underwent significant unexpected changes, supporting the evidence that ENS do not play an exclusive role in the pathways of intestinal motility disorders.But de l’étudeL’atrésie intestinale est une anomalie congénitale définie par une perte de la continuité digestive. Malgré une restauration chirurgicale précoce de cette continuité, surviennent durant les premiers mois de vie des troubles de la motilité digestive et des surinfections bactériennes chez un tiers des patients. Ces troubles fonctionnels étaient attribués jusque là principalement à des altérations du système nerveux entérique. Le but de cette étude était de confirmer cette hypothèse mais également d’élargir le champ des explorations aux autres composants du tube digestif.Matériel et méthodesLe modèle animal de l’atrésie chez le rat initialement décrit dans notre équipe a été utilisé pour caractériser les anomalies d’expression génique par transcriptomique. L’étude portait également sur la maturation digestive chez des fœtus de rat contrôle entre un stade de développement embryonnaire E15 et E21. Des modifications en amont et en aval de l’obstruction ont été étudiées en prélevant deux segments successifs de 1 cm par cette approche globale transcriptomique puis précisées par RT-PCRq et confirmées par des techniques immunohistochimiques et de microscopie électronique. RésultatsChez les fœtus témoins, l’expression génique montre une décroissance physiologique pour le SNE et une augmentation pour les systèmes neuroendocrine et épithélial de E15 à E21. Concernant les fœtus avec atrésie, les modifications concernent quasi exclusivement le segment d’amont avec une augmentation du calibre intestinal, de l’épaisseur musculaire et une accélération globale de la maturation. Une redistribution des sous types neuronaux est constatée dans le segment d’amont ainsi qu’une augmentation de l’expression du système neuro endocrine. Pour ces deux systèmes, le segment d’aval est peu modifié. Des modifications importantes du système épithélial sont observées en amont comme en aval avec pour conséquence probable une altération de la barrière intestinale et du système anti infectieux.ConclusionCes résultats montrent que les changements prédominent dans le segment en amont de l’atrésie alors que le segment d’aval était parfois considéré comme le plus pathologique. De plus, il a été retrouvé des changements inattendus du système neuroendocrine et épithélial qui sous tendent une implication non exclusive du SNE. D’autres recherches sont nécessaires pour confirmer ces données et les exploiter dans une démarche thérapeutique

Disorders of the intestinal wall in a rat model of intestinal obstruction : implication of the enteric nervous system and neuroendocrine system

But de l’étudeL’atrésie intestinale est une anomalie congénitale définie par une perte de la continuité digestive. Malgré une restauration chirurgicale précoce de cette continuité, surviennent durant les premiers mois de vie des troubles de la motilité digestive et des surinfections bactériennes chez un tiers des patients. Ces troubles fonctionnels étaient attribués jusque là principalement à des altérations du système nerveux entérique. Le but de cette étude était de confirmer cette hypothèse mais également d’élargir le champ des explorations aux autres composants du tube digestif.Matériel et méthodesLe modèle animal de l’atrésie chez le rat initialement décrit dans notre équipe a été utilisé pour caractériser les anomalies d’expression génique par transcriptomique. L’étude portait également sur la maturation digestive chez des fœtus de rat contrôle entre un stade de développement embryonnaire E15 et E21. Des modifications en amont et en aval de l’obstruction ont été étudiées en prélevant deux segments successifs de 1 cm par cette approche globale transcriptomique puis précisées par RT-PCRq et confirmées par des techniques immunohistochimiques et de microscopie électronique. RésultatsChez les fœtus témoins, l’expression génique montre une décroissance physiologique pour le SNE et une augmentation pour les systèmes neuroendocrine et épithélial de E15 à E21. Concernant les fœtus avec atrésie, les modifications concernent quasi exclusivement le segment d’amont avec une augmentation du calibre intestinal, de l’épaisseur musculaire et une accélération globale de la maturation. Une redistribution des sous types neuronaux est constatée dans le segment d’amont ainsi qu’une augmentation de l’expression du système neuro endocrine. Pour ces deux systèmes, le segment d’aval est peu modifié. Des modifications importantes du système épithélial sont observées en amont comme en aval avec pour conséquence probable une altération de la barrière intestinale et du système anti infectieux.ConclusionCes résultats montrent que les changements prédominent dans le segment en amont de l’atrésie alors que le segment d’aval était parfois considéré comme le plus pathologique. De plus, il a été retrouvé des changements inattendus du système neuroendocrine et épithélial qui sous tendent une implication non exclusive du SNE. D’autres recherches sont nécessaires pour confirmer ces données et les exploiter dans une démarche thérapeutique.Aim of the studyIntestinal atresia is a rare congenital affection with postoperative motility disorders, leading sometimes to death. Previous related studies mainly focused on enteric nervous system (ENS) alterations as it was identified to cause abnormal peristalsis. The aim of the study was to expertise the underlying pathological conditions of intestinal atresia using a global approach, before focusing on ENS and neuroendocrine cells in order to precise the presumptive involvement of the different layers of the intestinal wall.MethodsPreliminary transcriptomic approach was elected to screen global gene expression involved in intestinal development and atresia-linked disorders in the rat model previously described by our team. Rat embryos were assigned to atretic group and controls embryos at different stages of development ED15, ED17, ED19 and ED21. Two successive intestine samples of 1 cm were harvested in the proximal segment and in the distal one. The pattern of gene expression was further assessed by immunohistochemistry, electron microscopy and RT-qPCR. Main resultsA physiological decrease in gene expression for enteric nervous system markers and an increase for neuroendocrine and epithelial system was observed on controls from stages ED15 to ED21. Regarding affected embryos, structural modifications concerned the proximal segment with increased muscular layer and a significant disruption including global accelerated maturation was observed in the proximal segment with increased gene expression of neuroendocrine system. Distal segment was comparable to controls for the two systems. Important modifications were noted concerning the epithelial system with consequent abnormalities of the gut barrier and anti infectious functions.ConclusionsFetal intestinal obstruction results in a disrupted gut development predominant in the proximal segment. The distal segment and the ENS were poorly concerned by theses changes. Neuroendocrine and epithelial cells underwent significant unexpected changes, supporting the evidence that ENS do not play an exclusive role in the pathways of intestinal motility disorders

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process

Abstract Background The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history. Methods Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses. Results 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4. Conclusions There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration. Trial registration Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021). Clinical trials registration number ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021)

Involvement of the enteroendocrine system in intestinal obstruction.

Intestinal atresia, a rare congenital condition, is often associated with intestinal motility disorders despite adequate neonatal surgery. Previous studies have focused on changes in the enteric nervous system (ENS). We hypothesized that other components of the digestive tract could be involved in this condition.In a rat model of surgically-induced intestinal obstruction, a transcriptome analysis was performed to measure the global gene expression. Then, analyzes were focused on genes expressed in ENS and neuroendocrine cells. Rat fetus small intestines at different developmental stages (ED15, ED17, ED19 and ED21, (n = 22)) were studied as controls and compared to the upper and lower segments of small intestines from rat fetuses with surgically-induced obstruction (n = 14; ligature at ED18). The gene expression pattern was confirmed by immunohistochemistry, electron microscopy and RT-qPCR.From ED15 to ED21, there was a physiological decrease in the gene expression of ENS markers and an increase in that of neuroendocrine genes. Regarding operated embryos, the changes in global gene expression were significantly higher in the proximal segment compared to the distal segment (18% vs. 9%). More precisely, a decrease in ENS gene expression and an increase in neuroendocrine gene expression were observed in the proximal segment compared to controls, indicating an accelerated maturation pattern. Immunohistochemistry and electron microscopy confirmed these findings.Fetal intestinal obstruction seems to induce an accelerated maturation in the proximal segment. Moreover, neuroendocrine cells undergo significant unexpected changes, suggesting that ENS changes could be associated with other changes to induce intestinal motility disorders

Epithelial changes of congenital intestinal obstruction in a rat model

International audienceIntroduction: Intestinal atresia is a rare congenital affliction that is often associated with severe bacterial infections despite adequate neonatal surgery. Previous studies have focused on enteric nervous system variations. We hypothesized that epithelial systems (ES) may also be involved in the pathophysiology of postnatal disorders.Materials and methods: Global gene expression was measured by transcriptomic analysis in a rat model of induced intestinal atresia. The analyses then focused on genes involved in ES (enterocytes and goblet cells). Rat fetus small intestines at various stages of development (ED15, ED17, ED19, and ED21, n = 22), were used as non-operated controls and compared to the upper and lower segments of rat fetus small intestines with an induced atresia (n = 14; ligature at ED18). The pattern of gene expression was then confirmed by histochemistry, electron microscopy, and RT-qPCR.Results: From ED15 to ED21, the expression of several genes exhibited a physiological increase of ES markers, with a significant increase at the end of gestation. The operated embryos exhibited significantly higher variations of gene expression in the proximal segment than in the distal segment in terms of absorption and the epithelial barrier. An increase in goblet cells and markers was observed in the proximal segment compared to the controls.Conclusion: Fetal intestinal obstruction accelerates maturation in the proximal segment and disrupts the intestinal wall in the distal segment, with a decrease in the number of mucosal cells. Moreover, the epithelial cells underwent significant changes, supporting the notion that intestinal disorders involve more than the ENS