1
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Low YX, Teo YM, Lee YY, Nyo YL, Loh DL, Mali VP. Navigating Inconclusive Upper-Gastrointestinal Series in Infantile Bilious Vomiting: A Case Series on Intestinal Malrotation. Am J Case Rep 2024; 25:e943056. [PMID: 38483097 PMCID: PMC10949343 DOI: 10.12659/ajcr.943056] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/26/2024] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Bilious vomiting in a child potentially portends the dire emergency of intestinal malrotation with volvulus, necessitating prompt surgical management, with differentials including small-bowel atresia, duodenal stenosis, annular pancreas, and intussusception. Although the upper-gastrointestinal series (UGI) is the diagnostic investigation of choice, up to 15% of the studies are inconclusive, thereby posing a diagnostic challenge. CASE REPORT We report a case series of 3 children referred for bilious vomiting, whose initial UGI was inconclusive and who were eventually confirmed to have intestinal malrotation at surgery. The first child was a female born at 37 weeks with antenatally diagnosed situs inversus and levocardia, who developed bilious vomiting on day 1 of life. The duodenojejunal flexure (DJ) could not be visualized on the UGI because of faint opacification on first pass of the contrast and subsequent overlap with the proximal jejunal loops. The second child was a male born at 36 weeks, presenting at age 4 months with bilious vomiting of 2 days duration. The third child was a female born at 29 weeks, presenting with bilious aspirates on day 3 of life. UGI for all 3 showed persistent hold-up of contrast at the proximal duodenum with no opacification of the distal duodenum or small bowel.Adjunctive techniques during the UGI and ultrasound examination helped achieve a preoperative diagnosis of malrotation in these children. CONCLUSIONS Application of diagnostic adjuncts to an inconclusive initial UGI may help elucidate a preoperative diagnosis of intestinal malrotation in infantile bilious vomiting.
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Affiliation(s)
- Yi Xian Low
- Department of Diagnostic Imaging, National University Hospital, Singapore City,Singapore
| | - Yi Ming Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore City,Singapore
| | - Yang Yang Lee
- Department of Paediatric Surgery, Khoo Teck Puat – National University Children’s Medical Institute, National University Hospital, Singapore City, Singapore
| | - Yoke Lin Nyo
- Department of Paediatric Surgery, Khoo Teck Puat – National University Children’s Medical Institute, National University Hospital, Singapore City, Singapore
| | - Dale Lincoln Loh
- Department of Paediatric Surgery, Khoo Teck Puat – National University Children’s Medical Institute, National University Hospital, Singapore City, Singapore
| | - Vidyadhar Padmakar Mali
- Department of Paediatric Surgery, Khoo Teck Puat – National University Children’s Medical Institute, National University Hospital, Singapore City, Singapore
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Kwa ZY, Li J, Loh DL, Lee YY, Liu G, Zhu L, Pikkarainen M, He H, Mali VP. An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation. JMIR Form Res 2024; 8:e52337. [PMID: 38363589 PMCID: PMC10907943 DOI: 10.2196/52337] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Circumcision as a common elective pediatric surgery worldwide is a stressful and anxiety-inducing experience for parents and children. Although current perioperative interventions proved effective, such as reducing preoperative anxiety, there are limited holistic solutions using mobile apps. OBJECTIVE This paper aims to describe the development and primary evaluation of an intelligent customer-driven smartphone-based app program (ICory-Circumcision) to enhance health outcomes among children undergoing circumcision and their family caregivers. METHODS Based on the review of the literature and previous studies, Bandura's self-efficacy theory was adopted as the conceptual framework. A multidisciplinary team was built to identify the content and develop the apps. Semistructured interviews were conducted to evaluate the ICory-Circumcision. RESULTS The ICory-Circumcision study was carried out from March 2019 to January 2020 and comprised 2 mobile apps, BuddyCare app and Triumf Health mobile game app. The former provides a day-by-day perioperative guide for parents whose children are undergoing circumcision, while the latter provides emotional support and distraction to children. In total, 6 participants were recruited to use the apps and interviewed to evaluate the program. In total, 4 main categories and 10 subcategories were generated from content analysis. CONCLUSIONS ICory-Circumcision seemed to lean toward being useful. Revisions to ICory-Circumcision are necessary to enhance its contents and features before advancing to the randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04174404; https://clinicaltrials.gov/ct2/show/NCT04174404.
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Affiliation(s)
- Zhi Yin Kwa
- Department of Nursing, National University Hospital, Singapore, Singapore
- National University Health System, Singapore, Singapore
| | - Jinqiu Li
- Nursing Department, Zhuhai Campus, Zunyi Medical University, Zhuhai, China
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Dale Lincoln Loh
- National University Health System, Singapore, Singapore
- Department of Paediatric Surgery, National University Hospital, Singapore, Singapore
| | - Yang Yang Lee
- National University Health System, Singapore, Singapore
- Department of Paediatric Surgery, National University Hospital, Singapore, Singapore
| | - Guangyu Liu
- Integrated Health Promotion, Ministry of Health Office for Healthcare Transformation, Singapore, Singapore
| | - Lixia Zhu
- Hôpital Chinois de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'Île-de-Montréal, Montreal, QC, Canada
| | - Minna Pikkarainen
- Department of Health Technology and Rehabilitation and Department of Product Design, Oslo Metropolitan University, Oslo, Norway
- Martti Ahtisaari Institute, Oulu Business School, University of Oulu, Oulu, Finland
| | - Honggu He
- National University Health System, Singapore, Singapore
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vidyadhar Padmakar Mali
- National University Health System, Singapore, Singapore
- Department of Paediatric Surgery, National University Hospital, Singapore, Singapore
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3
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Tan SB, Kumar KS, Truong ATL, Tan LWJ, Chong LM, Gan TRX, Mali VP, Aw MM, Blasiak A, Ho D. Comparing the Performance of Multiple Small-Data Personalized Tacrolimus Dosing Models for Pediatric Liver Transplant: A Retrospective Study. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38083591 DOI: 10.1109/embc40787.2023.10341002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Tacrolimus is a potent immunosuppressant used after pediatric liver transplant. However, tacrolimus's narrow therapeutic window, reliance on physicians' experience for the dose titration, and intra- and inter-patient variability result in liver transplant patients falling out of the target tacrolimus trough levels frequently. Existing personalized dosing models based on the area-under-the-concentration over time curves require a higher frequency of blood draws than the current standard of care and may not be practically feasible. We present a small-data artificial intelligence-derived platform, CURATE.AI, that uses data from individual patients obtained once daily to model the dose and response relationship and identify suitable doses dynamically. Retrospective optimization using 6 models of CURATE.AI and data from 16 patients demonstrated good predictive performance and identified a suitable model for further investigations.Clinical Relevance- This study established and compared the predictive performance of 6 personalized tacrolimus dosing models for pediatric liver transplant patients and identified a suitable model with consistently good predictive performance based on data from pediatric liver transplant patients.
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4
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Hidayah BA, Toh ZA, Cheng LJ, Syahzarin BD, Zhu Y, Pölkki T, He H, Mali VP. Enhanced recovery after surgery in children undergoing abdominal surgery: meta-analysis. BJS Open 2023; 7:zrac147. [PMID: 36662629 PMCID: PMC9856339 DOI: 10.1093/bjsopen/zrac147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a multimodal approach that streamlines patient processes before, during, and after surgery. The goal is to reduce surgical stress responses and improve outcomes; however, the impact of ERAS programmes in paediatric abdominal surgery remains unclear. The authors aimed to review the effectiveness of ERAS on clinical outcomes in children undergoing abdominal surgery. METHOD CINAHL, CENTRAL, Embase, ProQuest, PubMed, and Scopus were searched for relevant studies published from inception until January 2021. The length of hospital stay (LOS), time to oral intake, time to stool, complication rates, and 30-day readmissions were measured. Meta-analyses and subgroup analyses were conducted using RevMan 5.4 with a random-effects model. RESULTS Among 2371 records from the initial search, 111 articles were retrieved for full-text screening and 12 were included for analyses. The pooled mean difference (MD) demonstrated reduced LOS (MD -1.96; 95 per cent c.i. -2.75 to -1.17), time to oral intake (MD -3.37; 95 per cent c.i. -4.84 to -1.89), and time to stool (MD -4.19; 95 per cent c.i. -6.37 to -2.02). ERAS reduced postoperative complications by half and 30-day readmission by 36 per cent. Subgroup analyses for continuous outcomes suggested that ERAS was more effective in children than adolescents. CONCLUSION ERAS was effective in improving clinical outcomes for paediatric patients undergoing abdominal surgery.
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Affiliation(s)
- Bte Azahari Hidayah
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Zheng An Toh
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Ling Jie Cheng
- National University Health System, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Bin Daud Syahzarin
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Nursing, National University Hospital, Singapore
- National University Health System, Singapore
| | - Yi Zhu
- Department of Musculoskeletal Pain Rehabilitation, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tarja Pölkki
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
- Department of Children and Women, Oulu University Hospital, Oulu, Finland
| | - Honggu He
- National University Health System, Singapore
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5
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Kyaw L, Lai NM, Iyer SG, Loh DSKL, Loh SEK, Mali VP. Percutaneous transhepatic interventional therapy of portal vein stenosis in paediatric liver transplantation: A systematic review of efficacy and safety. Pediatr Transplant 2022; 26:e14187. [PMID: 34724594 DOI: 10.1111/petr.14187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 06/01/2021] [Revised: 10/01/2021] [Accepted: 10/22/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF THE SYSTEMATIC REVIEW To determine the efficacy and safety of percutaneous trans-hepatic balloon and/or stent angioplasty (PTA) in the management of portal vein (PV) stenosis following paediatric liver transplantation. METHODS Articles were included from a systematic search of Medline, Embase, Cochrane CENTRAL, ClinicalTrials.gov and International Clinical Trials Registry from inception to the 29th of August 2020. RESULTS There were 213 paediatric liver recipients who underwent PTA for PV stenosis in 19 included studies published between 1991 and 2019. Balloon angioplasty was the initial treatment in the majority (n = 153). Primary stent placement (n = 34) was performed for elastic recoil, intimal tears and PV kinks and rescue stent placement (n = 14) for recurrent PV stenosis following primary balloon angioplasty. The technical success was 97.6%-100% overall, 97.6%-100% for balloon-angioplasty-only and 100% for primary stenting. The clinical success was 50%-100% overall, 50%-100% for balloon-angioplasty-only and 100% for primary stenting. Long-term PV patency was 50%-100% overall, 37.5%-100% for balloon-angioplasty-only and 100% for primary stenting. Primary balloon angioplasty was successful in 78% of the cases. Of the recurrent PV stenoses, 9% resolved with stent placement and one required a meso-Rex shunt. There was one re-transplantation without stenting. The complication rate was 2.6% for balloon-angioplasty-only (bleeding, liver abscess, 2 PV thromboses) and 5.9% for primary stenting (bleeding, stent-fracture). There was no procedure-related mortality. CONCLUSION Percutaneous transhepatic balloon angioplasty may be the initial management of portal vein stenosis in paediatric liver recipients. Stent placement may be a primary option in selected cases and a reliable rescue option for recurrent portal vein stenosis following balloon-angioplasty-only.
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Affiliation(s)
- Lin Kyaw
- Department of Paediatric Surgery, National University Hospital, Singapore City, Singapore
| | - Nai Ming Lai
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Shridhar Ganpati Iyer
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore City, Singapore
| | | | - Stanley Eu Kuang Loh
- Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
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6
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Mali VP, Aw M, Ng KH, Karthik SV, Tan M, Teo S, Lau PYW, Nyo YL, Loh DSKL, Tiong HY, Quak SH, Yap HK. Paediatric living-donor liver and kidney transplantation during COVID-19. Ann Acad Med Singap 2022; 51:119-121. [PMID: 35224610 DOI: 10.47102/annals-acadmedsg.2021272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Vidyadhar Padmakar Mali
- Department of Paediatric Surgery, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore
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7
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Abstract
Mesenteric lymphatic malformations are rare benign tumors that are most commonly found in children. The presentation of these tumors can be variable. It has been suggested that mesenteric lymphatic malformations are congenital; however, there is evidence that their size may be increased by infection. A 3-year 10-month-old boy presented with rhinorrhea and cough followed by acute abdominal pain. Ultrasonography revealed a lobulated mass in the lower abdomen. Computerized tomography scan of the abdomen diagnosed an inflamed appendix with perforation. Laparotomy revealed a multicystic mass within the mesentery closely adherent to the ileum; with omentum wrapped around. The appendix was dilated and firm. An ileal resection and an appendicectomy were performed. Histology confirmed acute transmural appendicitis with concurrent cystic lymphangioma of the ileal mesentery. Although rare, cystic lymphangioma must be considered in the differential of pediatric acute abdomen. Surgeons must be aware of this association and be reminded to inspect the rest of small bowel during appendicectomy especially if the preoperative imaging is suspicious.
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Affiliation(s)
- Su-Ann Lui
- Department of Pediatric Surgery, National University of Hospital, Singapore
| | - Yoke Lin Nyo
- Department of Pediatric Surgery, National University of Hospital, Singapore
| | - V P Mali
- Department of Pediatric Surgery, National University of Hospital, Singapore
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8
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Kanazawa H, Fukuda A, Sato M, Ishimori S, Sasaki K, Uchida H, Shigeta T, Mali VP, Sakamoto S, Ishikura K, Kasahara M. Successful resumption of peritoneal dialysis following living donor liver transplantation in children with end-stage renal disease. Pediatr Transplant 2017; 21. [PMID: 28213931 DOI: 10.1111/petr.12897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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] [Accepted: 01/11/2017] [Indexed: 01/17/2023]
Abstract
Children with ESRD in need of RRT are commonly managed by PD due to difficulty with vascular access for HD and the relatively large extracorporeal blood volume required. Major abdominal surgery may result in injury to the peritoneum and consequent adhesion, thereby resulting in a reduction in the anatomical capacity and transport capability across the peritoneal membrane. Here, we report successful resumption of PD after LDLT in two pediatric patients. The causes of ESRD were PH1 and juvenile nephronophthisis, respectively. Both patients were managed by PD prior to LDLT. PD was converted to HD starting three days before LDLT and was continued postoperatively until resumption of PD on days 13 and 28, respectively. The PD weekly Kt/V urea was maintained before and after LDLT. The patients continued to do well on PD without complications. Meticulous intra-operative techniques during LDLT allow postoperative PD resumption by preservation of peritoneal integrity with effective transport capability and without added risk of peritonitis.
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Affiliation(s)
- Hiroyuki Kanazawa
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Shingo Ishimori
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Vidyadhar Padmakar Mali
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Mali VP, Fukuda A, Shigeta T, Uchida H, Hirata Y, Rahayatri TH, Kanazawa H, Sasaki K, de Ville de Goyet J, Kasahara M. Total internal biliary diversion during liver transplantation for type 1 progressive familial intrahepatic cholestasis: a novel approach. Pediatr Transplant 2016; 20:981-986. [PMID: 27534385 DOI: 10.1111/petr.12782] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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] [Accepted: 07/13/2016] [Indexed: 12/11/2022]
Abstract
LT for PFIC type 1 is often complicated by postoperative diarrhea and recurrent graft steatosis. A 26-month-old female child with cholestatic jaundice, pruritus, diarrhea, and growth retardation revealed total bilirubin 9.1 mg/dL, gamma-glutamyl transpeptidase 64 IU/L, and TBA 295.8 μmol/L. Genetic analysis confirmed ATP8B1 defects. A LT (segment 2, 3 graft) from the heterozygous father was performed. Biliary diversion was performed by a 35-cm jejunum conduit between the graft hepatic duct and the mid-transverse colon. Stools became pigmented immediately. Follow-up at 138 days revealed resolution of jaundice and pruritus and soft-to-hard stools (6-8 daily). Radioisotope hepato-biliary scintigraphy (days 26, 68, and 139) confirmed unobstructed bile drainage into the colon (t1/2 34, 27, and 19 minutes, respectively). Contrast meal follow-through at day 62 confirmed the absence of any colo-jejuno-hepatic reflux. At 140 days, contrast follow-through via the biliary stent revealed patent jejuno-colonic anastomosis and satisfactory transit. Graft biopsy at LT, 138 days, and 9 months follow-up revealed comparable grades of macrovesicular steatosis (<20%). TIBD during LT may be a clinically effective stoma-free biliary diversion and may prevent recurrent graft steatosis following LT for PFIC type 1.
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Affiliation(s)
- V P Mali
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan.
| | - A Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - T Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - H Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Y Hirata
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - T H Rahayatri
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - H Kanazawa
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - K Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - J de Ville de Goyet
- Department of Surgery and Transplantation Centre, Bambino Gesù Children's Hospital, Rome, Italy.,Paediatric Surgery Chair, Università di Roma Tor Vergata, Rome, Italy
| | - M Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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10
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Uchida H, Fukuda A, Sasaki K, Shigeta T, Hirata Y, Kanazawa H, Mali VP, Miyazaki O, Nosaka S, Sakamoto S, Mureo K. Reno- and splenoportal anastomosis for a retransplant patient with situs inversus. Pediatr Transplant 2016; 20:594-596. [PMID: 27029560 DOI: 10.1111/petr.12703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Abstract
PV thrombosis following pediatric LT is a serious complication that may lead to graft loss. LDLT poses limitations with regard to the availability of vein grafts for complex PV reconstructions. We herein report a unique reconstruction of the PV inflow in a one-yr-old boy with situs inversus undergoing re-LDLT. The inflow was derived from the SPV and the RRV. A common channel was created utilizing a donor IMV and the recipient explant LHV as vascular conduits. With the application of innovative surgical reconstructions, pre-existing portomesenteric thrombosis may be amenable to re-LDLT in the pediatric population.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshihiro Hirata
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Kanazawa
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Vidyadhar Padmakar Mali
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kasahara Mureo
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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11
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Kanazawa H, Fukuda A, Mali VP, Rahayatri TH, Hirata Y, Sasaki K, Uchida H, Shigeta T, Sakamoto S, Matsumoto K, Kasahara M. Chemotherapy-induced B-cell depletion in hepatoblastoma patients undergoing ABO-incompatible living donor liver transplantation. Pediatr Transplant 2016; 20:401-7. [PMID: 27012966 DOI: 10.1111/petr.12675] [Citation(s) in RCA: 2] [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] [Accepted: 12/23/2015] [Indexed: 12/19/2022]
Abstract
LT from ABO-I donors requires preconditioning regimens to prevent postoperative catastrophic AMR. NAC for HBL is known to cause myelosuppression leading to a reduction in the number and function of lymphocytes. We investigated this chemotherapy-induced myelosuppression in HBL patients listed for LT from ABO-I donors with reference to the kinetics of B, T cells, and anti-ABO blood type isoagglutinin titers. Between 2005 and 2015, of the 319 patients who underwent LDLT at our institute, 12 were indicated for unresectable HBL. Three patients with unresectable HBL who underwent LDLT from ABO-I donors are included in this study. Immunosuppression consisted of a standard regime of tacrolimus and low-dose steroids as in ABO compatible/identical LDLT. No additional preoperative therapies for B-cell depletion were used. Absolute lymphocyte counts, lymphocyte subsets (including CD20+ B cells, CD3+CD4+ T cells and CD3+CD8+ T cells), and anti-ABO blood type isoagglutinin titers were measured before LDLT and postoperatively. The median age at diagnosis was 19 months (range, 3-31 months). The median follow-up was seven months (range, 6-15 months). The median interval from the last NAC to LDLT was 33 days (range, 25-52 days). The median interval from LDLT to adjuvant chemotherapy was 28 days (range, 22-36 days). The counts of CD20+ B cells before LDLT were depleted to median 5 cells/mm(3) (range, 0-6 cells/mm(3)). There was a transient rebound in the CD20+ B cell counts on day seven (maximum of 82 cells/mm(3)) followed by a decline starting at 14 days after LDLT that was sustained for the duration of adjuvant chemotherapy. Anti-ABO blood type isoagglutinin titers were lowered to between 1:1 and 1:16 before LDLT and remained low for the duration of follow-up in this study. All of the three patients remained in good health without either acute cellular or AMR after LDLT. The B-cell depletion that occurs after cisplatin-based chemotherapy for HBL may help accomplish safe ABO-I LDLT in children without the use of additional conditioning regimens for prevention of AMR.
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Affiliation(s)
- Hiroyuki Kanazawa
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | | | - Tri Hening Rahayatri
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshihiro Hirata
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimikazu Matsumoto
- Department of Pediatric Hematology and Oncology Research, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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12
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Mali VP, Robless PA, Aw M, Loh DL, Quak SH, Prabhakaran K. Unusual shunt for symptomatic portal vein thrombosis after liver transplantation - Clatworthy revisited. Pediatr Transplant 2012; 16:E120-4. [PMID: 21834802 DOI: 10.1111/j.1399-3046.2011.01548.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PV thrombosis is not an uncommon occurrence following pediatric LT. Symptomatic PHT following PV thrombosis is treated medically, surgical portosystemic shunting (mesorex, splenorenal, and mesocaval) being reserved for refractory cases. A 10-yr-old boy suffered recurrent malena and hemorrhagic shock because of chronic PV thrombosis following LT nine yr ago (1999). Extensive work-up failed to localize the bleeding source. The liver function remained normal. Initial attempts at surgical shunts failed owing to thrombosis (mesocaval 2001, splenorenal, inferior mesenteric-left renal vein, splenic-left external iliac vein 2008). In this situation, we performed a Clatworthy shunt by anastomosing the divided lower end of the LCIV to the side of SMV. There was a single, large caliber anastomosis. Post-operatively, the malena stopped completely, and clinically, there was no lower limb edema or encephalopathy. Doppler USG revealed persistence of hepatopetal flow within the portal collaterals. Follow-up at two yr reveals stable hepatic function with a patent shunt. To the best of our knowledge, we are not aware of a Clatworthy shunt being performed in a transplant setting. We reviewed the literature pertaining to this shunt in non-transplant patients with PHT.
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Affiliation(s)
- V P Mali
- Departments of Paediatric Surgery, National University Hospital, Singapore.
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Mali VP, Tan HC, Loh D, Prabhakaran K. Inflammatory tumour of the retroperitoneum--a case report. Ann Acad Med Singap 2005; 34:632-5. [PMID: 16382249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Neoplastic growths of myofibroblasts occurring on a background of plasma cell and lymphocytic proliferation have been designated as inflammatory myofibroblastic tumours (IMTs). These unusual tumours were first described in pulmonary location in adults. Though extrapulmonary masses have been reported in children; retroperitoneal growths are exceedingly rare. We report a case of retroperitoneal IMT that presented with constitutional symptoms without any palpable abdominal mass. CLINICAL PICTURE A previously well 12-year-old boy presented with fever, right-sided flank pain and weight loss of 1-month duration. There were no foci of infection. The erythrocyte sedimentation rate (ESR) was raised; the white cell count was normal. An abdominal computed tomography (CT) scan revealed a right suprarenal tumour measuring 3.5 cm without any calcification. The urinary catecholamines and vanilmandelic acid were normal. TREATMENT A laparotomy with complete excision of the tumour was performed. Final histology revealed an inflammatory myofibroblastic tumour without any correlates of aggressive behaviour. OUTCOME Postoperatively, the constitutional symptoms of fever, weight loss and raised ESR normalised. Follow-up CT was normal and further treatment was not necessary. CONCLUSION Although rare, IMTs should be considered in any abdominal solid tumour with associated constitutional and laboratory features of an inflammatory response. Complete surgical excision is effective treatment for biologically benign tumours.
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Affiliation(s)
- V P Mali
- Department of Paediatric Surgery, National University Hospital, Singapore
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Abstract
PURPOSE The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele. METHODS The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation. RESULTS The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia. CONCLUSIONS The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.
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Affiliation(s)
- V P Mali
- Department of Paediatric Surgery, National University Hospital, Singapore
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Abstract
Congenital anorectal malformations are relatively common, and associated genitourinary malformations have been reported in up to 40% of patients. Uterovaginal malformations are also not rare in children. They are known to occur with increased frequency in children with anorectal malformations, but the diagnosis may still be difficult. We report herein one such case of anorectal malformation associated with congenital total absence of the vagina in which the uterovaginal malformation was not diagnosed until the operative repair of the anorectal malformation. The operative procedure was thereafter directed, along with the anorectoplasty, towards restoring a functional uterovaginal tract. Review of the literature revealed that such a diagnosis is unsuspected or delayed in more than half of affected patients. Furthermore, these patients present with many diagnostic and therapeutic problems. Our report highlights the need to be aware of this condition to allow for an earlier diagnosis and appropriate operative treatment.
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Affiliation(s)
- J Z Patankar
- Department of Paediatric Surgery, National University Hospital, 5 Lower Kent Ridge Road, 119074 Singapore, Republic of Singapore.
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Patankar JZ, Mali VP, Prabhakaran K. Neonatal adrenal haemorrhagic pseudocyst. J Postgrad Med 2002; 48:239-40. [PMID: 12432209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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