LAPAROSCOPIC SANTULLI INTESTINAL ANASTOMOSIS IN AN INFANT WITH CYSTIC FIBROSIS

The aim of the study was to evaluate the technical feasibility of performing a Santulli-type side-toend inter-intestinal anastomosis in infants with cystic fibrosis (CF) using laparoscopy. A clinical case of a 3-month-old child with CF who was operated on in the neonatal period for meconium ileus is presented. The baby's gestational age was 32 weeks. The primary operation consisted of the formation of a terminal enterostomy. In the postoperative period, a malabsorption syndrome was noted, accompanied by a lack of growth. As a temporary measure to restore nutritional status, a Santulli-style side-to-end laparoscopic intestinal anastomosis was performed. The observed child was found to have the F508del mutation in both alleles of the CFTR gene. The patient's weight at the time of the Santulli anastomosis construction was 2900 g, the age – 3 months. During the operation, there were no difficulties associated with the mobilization of the separated segments of the ileum. The duration of the surgical intervention was 70 min. Enteral nutrition was started on the 3rd day after the operation. The recovery period for intestinal transit through the rectum was 15 days. The postoperative period was uneventful. The duration of hospitalization was 18 days. No electrolyte imbalance or excessive fluid loss or underweight associated with enterostomy was observed. Over the next 6 months, the normalization of age-related weight and height parameters was achieved, after which the continuity of the digestive tract was restored by closing the terminal enterostomy. Currently, the patient has minimal respiratory symptoms and is receiving adequate CF therapy with pancreatic enzyme replacement therapy included with each meal. The initial experience of performing laparoscopic Santulli inter-intestinal anastomosis in an infant with CF presented in the study showed the possibility and reproducibility of this technique, expanding the boundaries of laparoscopy in pediatric practice. The decision to close the enterostomy in these patients should be deferred until a full diet is introduced and should be made in conjunction with a pediatrician specializing in the treatment of CF.

Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas

Background Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure. Methods Patients 19 years and younger who were treated at a single children’s hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes. Results Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use ( P = .015), shorter time to full diet ( P = .030), and post-operative length of stay ( P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume. Discussion Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.

588 Caloric restriction sensitizes melanoma to anti-PD-1 immune checkpoint inhibition

BackgroundIndividual response to immune checkpoint inhibition (ICI) in patients with metastatic melanoma varies from 10–40% for monotherapy and 50–60% with combination therapy [1]. Identification of adjuncts to ICI to further bridge treatment response to cure is imperative. We focus on caloric restriction (CR) as an adjunct to anti-PD-1 ICI given its inexpensive nature, relative ease of application, and increased tolerability as compared to fasting.Methods12-week C57BL/6J mice were inoculated with Yale University Mouse Melanoma (YUMM 1.7), randomized into diet groups and further randomized into αPD-1 and control (IgG) groups on day 12 (D12). Full diet mice ad lib fed while CR mice were 40% calorically restricted based on average daily food intake. Tumors were measured every 3 days with digital calipers (q3d). αPD-1 or control was intraperitoneally injected starting D12 continuing q3d for 7 injections. Mice were sacrificed and tumors harvested on D31. RNA sequencing was performed on CD45+ CD3+ T cells.ResultsUnder CR conditions, mice treated with αPD-1 had significantly smaller tumor volumes compared to the full diet cohort treated with αPD-1 (D22, 271.15 m3 vs. 336.72 m3, p=0.031) and persisted to harvest (D31, 600.96 m3 vs. 1039.84 m3, p=0.034). A significant difference in tumor volumes between CR αPD-1 and CR control treated cohorts was observed starting at D28 (439.34 m3 vs. 667.63 m3, p=0.005) and persisted to harvest (D31, 600.96 m3 vs. 884.08 m3, p=0.009). However, no significant difference in tumor growth under full diet conditions in murine cohorts treated with αPD-1 or control or separately between CR and full diet cohorts treated with control was observed.On pathway enrichment analysis inflammatory response, cytokine-mediated, response to interferon-gamma, and cell proliferation pathways were downregulated in the CR + αPD-1 cohort. Notable genes found in these pathways include B-cell linker protein (BLNK), tyrosine-protein kinase Lyn (LYN), SYK (spleen tyrosine kinase), toll-like receptor (TLR) TLR4, TLR7, and TLR8.ConclusionsCaloric restriction significantly sensitizes YUMM 1.7 murine melanoma to anti-PD-1 therapy resulting in decreased tumor growth. We show significant modulation of tumor growth in a murine tumor cell line, which has previously demonstrated limited response to αPD-1. In the present study, caloric restriction may decrease inflammation via downregulation of cytokine and toll-like receptor mediated pathways. Furthermore, caloric restriction may reverse the immunosuppressive tumor microenvironment and provide an inexpensive means to increase treatment response to anti-PD-1 therapy.ReferencesWard WH, Farma JM. Cutaneous Melanoma: Etiology and Therapy. Brisbane (AU): Codon Publications. 2017; Chapter 8.Ethics ApprovalThis study was approved by the University Committee on Animal Resources (UCAR), UCAR-2018-014.

Chylous ascites following elective abdominal aortic aneurysm repair

Postoperative chylous ascites is a rare complication of abdominal surgery. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a serious and potentially life-threatening condition for which prompt diagnosis and management is imperative. A 72-year-old male was referred for open repair of a 62 cm juxtarenal abdominal aortic aneurysm (AAA). Following resumption of diet, he developed abdominal distention. Therapeutic paracenteses confirmed chylous ascites. Failed conservative management and lymphatic embolization lead to surgical sealance of lymphatic leak using glue. Postoperatively, a full diet was tolerated with no further ascites. Paracentesis is the diagnostic modality of choice in evaluating patients with ascites. Management is challenging and should be multifaceted and tailored to individual patient needs. Cornerstones of therapy include correction of the underlying etiology and conservative measures. When conservative measures fail, other interventions can be considered, such as somatostatin analogs, surgical ligation or glue embolization.

A Pilot Study of Enhance Recovery after Surgery (ERAS) for Liver Resection

Background: Morbidity post hepatectomy still remain persistent throughout decades compared to other surgery. Modern approach have been introduced to improve safety and reduce morbidity whilst at the same time enhance patient recovery. Thus, enhanced recovery after surgery or fast track recovery program for liver resection was initiated. Objective: The aim of this study was to achieve discharge by postoperative day 3 for minor resection and day 5 for major resection. Design and Setting: This is a prospective study conducted in Hospital Universiti Kebangsaan Malaysia (HUKM) from September 2014 till April 2015. Material and Methods: All patients undergoing open liver resection were included in the study. They were then managed post operatively according to ERAS protocol that was drawn up based on previous studies. Patient’s demographics data, intra operative parameters, postoperative complications and adherence to postoperative recovery protocol were recorded. Results: Seventeen patients (7 major and 10 minor resection) were recruited. The mean length of hospital stay for minor resection was 5.9 and major resection was 9.6 .With regards to the targets, 4 out of 10 (40%)patients in minor resection group and 4 out 7 (57.1%) in the major group were discharged on time. 9 patients had postoperative complications with no mortality recorded. In terms of the ERAS protocol targets, the PCA morphine discontinuation target was achieved in 15 patients (88.3%) ,nasogastric tube removal (13 patients -76.5%) , urinary cathether removal (6 patients - 35.3%), abdominal drains removal (9 patients-52.9%) and resumption of full diet was achieved by 82.4% (14 patients). Conclusion: From these overall achievement, most of our targets have been met and this shows that our ERAS protocol is safe to be applied to patient undergoing hepatectomy. Limitations: Some patients had achieved their target but not discharged for unknown reason.

Aspectos terapêuticos e nutricionais de neonatos submetidos a correção de atresia esofágica

Descrever as variáveis neonatais, condições clínicas e nutricionais de recém-nascidos portadores de Atresia Esofágica submetidos a correção cirúrgica. Estudo documental, retrospectivo e quantitativo em 50 prontuários de neonatos portadores de atresia de esôfago, internados em um hospital de referência. Na amostra: 96% das genitoras realizaram o pré-natal, com 64% nascidos de parto cesáreo, sendo 62% do sexo feminino e 60% dos neonatos nasceram com peso normal. Sobre a classificação da Atresia Esogágica, 84% tipo C. A média da amostra foi de 10 dias de vida a submissão da cirurgia de correção e 20 dias de vida para introdução da dieta. A idade média no alcance da dieta plena foi de 30 dias, sendo em torno do 21º dia de pós-operatório. A amamentação foi informada em 44% da amostra. Predominou consonâncias entre as variáreis do estudo comparadas com publicações nacionais e internacionais sobre o tema.Descritores: Atresia Esofágica, Anormalidades Congênitas, Enfermagem Pediátrica. Therapeutic and nutritional aspects of neonates submitted to esophageal atresia correctionAbstract: To describe the neonatal variables, clinical and nutritional conditions of newborns with esophageal atresia who underwent surgical correction. This is a documentary, retrospective and quantitative study of 50 medical records of neonates with Esophageal Atresia, admitted in a reference hospital. In the sample: 96% of mothers received prenatal care, with 64% of infants born by cesarean delivery, 62% of whom were female and 60% of neonates were born with normal weight. Regarding the classification of Esophageal Atresia, 84% were classified as type C. The sample mean was being 10 days old until the moment that the newborn underwent correction surgery and 20 days old to introduce the diet. The average age to tolerate the full diet was 30 days, being around the 21st postoperative day. Breastfeeding was reported in 44% of the sample. There was a consonance between the study variables compared to national and international publications on the subject.Descriptors: Esophageal Atresia, Congenital Abnormalities, Pediatric Nursing. Aspectos terapéuticos y nutricionales de los neonatos sujetos a la corrección de la atresia esofágicaResumen: Describir las variables neonatales, las condiciones clínicas y nutricionales de los recién nacidos con atresia esofágica sometidos a corrección quirúrgica. Estudio documental, retrospectivo y cuantitativo de 50 registros médicos de recién nacidos con atresia esofágica, internados en un hospital de referencia. En la muestra: 96% de las madres realizaron atención prenatal, 64% nacieron por cesárea, 62% de las cuales eran del sexo feminino y 60% de los recién nacidos teníam peso normal. Con respecto a la clasificación de la Atresia de Esófago, 84% eran del tipo C. La media de la muestra fue de 10 días hasta el momento de la realización de la cirugía de corrección y de 20 días para introducir la dieta. La media de edad para alcanzar la dieta completa fue de 30 días, alrededor del día 21 de postoperatorio. La lactancia materna se informó en 44% de la muestra. Hubo una consonancia entre las variables de estudio en comparación con las publicaciones nacionales e internacionales sobre el tema.Descriptores: Atresia Esofágica, Anomalías Congénitas, Enfermería Pediátrica.

Phenolic profile and antioxidant activity of bee pollen extracts from different regions of Algeria

Due to its complex biochemical properties, the bee pollen is considered one of the functional foods. Bee pollen collected from pollen grains from different botanical sources offers almost a full diet such as carbohydrates, proteins, amino acids, vitamins, minerals. In this study, methanol extracts of 13 honeybee pollen samples were evaluated for flavonoids, phenolic compounds, and antioxidant capacity. Caffeic acid, chlorogenic acid, vanillic acid, p-coumaric acid, gallic acid, quercetin, rutin, vanillin, and naringin were identified as main phenolic compounds in pollen extracts by High-Performance Liquid Chromatography (HPLC) analysis. The obtained results are: total phenolic content - 379.8 to 915.6 mg GAE/100 g, total flavonoid content - 207.1 to 550 mg QE/100 g, and antioxidant activity - 808.2 to 3311 mg GAE/100 g in bee pollen extracts.

Enhanced Recovery after Surgery (ERAS) Protocols versus Standard Care in Perioperative Management of Radical Cystectomy with Urinary Diversion

Background Bladder cancer is the ninth most common cancer worldwide, with an estimated 430 000 new cases in 2012. Bladder cancer has more than 130,000 deaths per year worldwide, with an estimated male: female ratio of 3.8:1.0. Aim of the Work to examine the current evidence for ERAS in preoperative, intraoperative and post-operative setting of care for RC patients, to propose ERAS evidence-based protocol for patients undergoing Radical Cystectomy in Egypt environment and to compare the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy including Length of Hospital Stay,bowel movement, Complications and Readmission Rate in 30Day. Patients and Methods This is a prospective randomized comparative study done at the urology departments of Ain Shams University and Nasser institute for research and treatment in 2018. Forty patients were included in this study who were indicated For Radical Cystectomy. They were recruited and randomized in two groups: Group A: where they followed enhanced recovery after Surgery protocols and Group B: where they followed the the classic pre-operative and post-operative protocols. Results We finished to that Enhanced recovery after surgery (ERAS) protocols in radical cystectomy is safe and not associated with any increase in intraoperative and post-operative complications compared to standard protocol. It is associated with reductions in the length of hospital stay, time to return to full diet, time to flatulence, time for defecation and pain post-operative. There is no difference in 30 day readmission rate between ERAS and Standard Care. Our prospective randomized controlled trial covers most of the items recommended for ERAS excluding the use of a laparoscopic or robotic approach, Audit, and use of alvimopan, a peripherally acting μ-opioid antagonist, which is not available in Egypt. Our study reveals many issues that need to be considered when designing a larger more powered study. Conclusion Enhanced recovery after surgery (ERAS) protocols in radical cystectomy is safe and not associated with any increase in intraoperative and post-operative complications compared to standard protocol. It is associated with reductions in the length of hospital stay, time to return to full diet, time to flatulence, time for defecation and pain post operative. There is no difference in 30 day readmission rate between ERAS and Standard Care.

Health effects of a low-inflammatory diet in adults with arthritis: a systematic review and meta-analysis

The aim is to systematically assess the health impact of a low-inflammatory diet intervention (full-diet or supplement), compared to usual diet or other dietary interventions, on weight change, inflammatory biomarkers, joint symptoms, and quality of life in adults with osteoarthritis, rheumatoid arthritis or seronegative arthropathy (psoriatic, reactive, ankylosing spondylitis or IBD-related), on outcomes assessed in prospective studies within 6 months of intervention commencement (PROSPERO CRD42019136567). Search of multiple electronic library databases from inception to July 2019, supplemented by grey literature searches, for randomised and prospective trials assessing the above objective. After exclusion of 446 ineligible studies, five randomised and two prospective trials involving 468 participants with either osteoarthritis or rheumatoid arthritis were included. GRADE assessment for all outcomes was very low. Meta-analyses produced the following standardised mean differences (SMD) and 95 % confidence interval (CI) 2–4 months following commencement of the diets favouring the low-inflammatory diet: weight SMD −0⋅45 (CI −0⋅71, −0⋅18); inflammatory biomarkers SMD −2⋅33 (CI −3⋅82, −0⋅84). No significant effects were found for physical function (SMD −0⋅62; CI −1⋅39, 0⋅14), general health (SMD 0⋅89; CI −0⋅39, 2⋅16) and joint pain (SMD −0⋅98; CI −2⋅90, 0⋅93). In most studies, the quality of dietary intervention (dietitian input, use of validated dietary compliance tool) could not be gauged. In conclusion, very low-level evidence suggests that low-inflammatory diets or supplements compared to usual diets are associated with greater weight loss and improvement in inflammatory biomarkers. More high-quality trials are needed to assess the health effects of a low-inflammatory diet more comprehensively and conclusively in arthritic conditions.

Comparison of mechanical sorting and DNA metabarcoding for diet analysis with degraded wolf scats

DNA metabarcoding has become a powerful technique for identifying species and profiling biodiversity with the potential to improve efficiency, reveal rare prey species, and correct mistaken identification error in diet studies. However, the extent to which molecular approaches agree with traditional approaches is unknown for many species. Here, we compare diets from wolf scats profiled using both mechanical sorting and metabarcoding of amplified vertebrate DNA sequences. Our objectives were: (1) compare findings from mechanical sorting and metabarcoding as a method of diet profiling and (2) use results to better understand diets of wolves on Prince of Wales Island, a population of conservation concern. We predicted metabarcoding would reveal both higher diversity of prey and identify rare species that are overlooked with mechanical sorting. We also posited that the relative contribution of Sitka black-tailed deer (Odocoileus hemionus sitkensis) and beaver (Castor canadensis) would be overestimated with mechanical sorting methods because of the failure to account for the full diet diversity of these wolves. We found that there was substantial overlap in the diets revealed using both methods, indicating that deer, beaver, and black bear (Ursus americanus) were the primary prey species. However, there was a large discrepancy in the occurrence of beaver in scats (54% and 24% from mechanical sorting and metabarcoding, respectively) explained by the high rate of false positives with mechanical sorting methods. Metabarcoding revealed more diet diversity than mechanical sorting, thus supporting our initial predictions. Prince of Wales Island wolves appear to have a more diverse diet with greater occurrence of rare species than previously described including 14 prey species that contribute to wolf diet. Metabarcoding is an effective method for profiling carnivore diet and enhances our knowledge concerning the full diversity of wolf diets, even in the extremely wet conditions of southeast Alaska, which can lead to DNA degradation. Given the increasingly efficient and cost-effective nature of collecting eDNA, we recommend incorporating these molecular methods into field-based projects to further examine questions related to increased use of alternate prey coinciding with changes in abundance of primary prey and habitat alteration.