The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with ...1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.
Abstract
Nearly all current simulations predict that outcomes of the star formation process, such as the fraction of stars that form in bound clusters (Γ), depend on the intensity of star formation ...activity (Σ
SFR
) in the host galaxy. The exact shape and strength of the predicted correlations, however, vary from simulation to simulation. Observational results also remain unclear at this time, because most works have mixed estimates made from very young clusters for galaxies with higher Σ
SFR
with those from older clusters for galaxies with lower Σ
SFR
. The three blue compact dwarf (BCD) galaxies ESO 185-IG13, ESO 338-IG04, and Haro 11 have played a central role on the observational side because they have some of the highest known Σ
SFR
and published values of Γ. We present new estimates of Γ for these BCDs in three age intervals (1–10 Myr, 10–100 Myr, 100–400 Myr), based on age-dating, which includes H
α
photometry to better discriminate between clusters younger and older than ≈10 Myr. We find significantly lower values for Γ(1–10 Myr) than published previously. The likely reason for the discrepancy is that previous estimates appear to be based on age–reddening results that underestimated ages and overestimated reddening for many clusters, artificially boosting Γ(1–10 Myr). We also find that fewer stars remain in clusters over time, with ≈15%–39% in 1–10 Myr clusters, ≈5%–7% in 10–100 Myr clusters, and ≈1%–2% in 100–400 Myr clusters. We find no evidence that Γ increases with Σ
SFR
. These results imply that cluster formation efficiency does not vary with star formation intensity in the host galaxy. If confirmed, our results will help guide future assumptions in galaxy-scale simulations of cluster formation and evolution.
Abstract We present a new study of the cluster populations in the blue compact dwarf galaxies (BCD) ESO185-IG13, ESO338-IG04, and Haro11, based on new and archival high-resolution images taken by the ...Hubble Space Telescope, and the first to probe the populations older than ≈100 Myr. BCDs are believed to experience intense bursts of star formation (including at the present day) after long periods of quiescence, but little is known about the timing, frequency, duration, and strength of these bursts or about their star formation histories in general. We find that the cluster population in each of the three galaxies studied here has its own unique distribution of colors and hence a unique cluster and star formation history. From an assumed correlation between the normalization of the cluster mass function and the star formation rate of the host galaxy, we construct cluster-based star formation histories over the past ≈few × Gyr and find that only Haro11 is currently experiencing a burst (≈factor of 10 increase in the rate of star formation for the last ≈20 Myr), whereas ESO185 experienced enhanced star formation (by a factor ≈4) between 10 and 40 Myr ago, and ESO338 has had a fairly constant SFH over the past few Gyr. These findings indicate that not all BCDs are experiencing a burst of star formation at the present day, and that some have been forming stars and clusters at a fairly steady rate (within a factor of ≈2–3) over the past few Gyr. This scenario is similar to the histories of dwarf irregular and dwarf starburst galaxies, which have star formation rates that are 10–1000 times lower than those in BCDs.
Abstract Background Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000's. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) ...and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC). Methods We retrospectively reviewed 68 laparoscopic-assisted TPCs and 39 open TPCs performed at our institution for UC between January 1997 and February 2011. Case duration, postoperative length of stay, and complications of the two groups were compared, and multivariable analysis was applied. Results The two groups were comparable with respect to gender, age, and postoperative length of stay. Total abdominal colectomy (TAC) duration was significantly longer in the laparoscopic-assisted group ( P < .001). Complications were similar in the laparoscopic and open group, although small bowel obstruction (SBO) was significantly less frequent in the laparoscopic group (log-rank test = 8.88, P = .003). Kaplan–Meier estimated freedom from SBO at 1 year follow-up is 99% for patients treated laparoscopically (95% CI: 98%–100%) and 76% for those undergoing an open surgical approach (95% CI: 64%–88%). Conclusions The significantly lower SBO rate, low complication rates, and equivalent length of stay favor use of the laparoscopic-assisted approach for TPC and IPAA in children.
Infliximab (IFX) has become a mainstay of therapy for children with Crohn disease (CD). Despite medical advances, many children with CD, however, still require operative interventions. The risk of ...complications following resection in children treated with IFX remains largely unknown. We compare surgical outcomes stratified by IFX therapy in a cohort of children with CD who require bowel resection.
We reviewed the postoperative complications in 123 children with CD who underwent bowel resection with primary anastomosis at our institution between 1977 and 2011. Demographics, medications, types of operations, and inpatient courses were analyzed. Complications and length of stay were compared based on medical therapy.
Overall, the postoperative complication rate was 13%. Of the 123 surgical cases, 24 children had received IFX before their operation. In the children treated with IFX, we identified 3 major complications, including anastomotic leak, acute renal failure, and intraabdominal abscess. There were 9 major complications in the non-IFX group, including infections (2), intraabdominal abscesses (2), bowel obstruction, shock, supraventricular tachycardia, phlegmon, and anastomotic stricture. No significant differences in complication rates or postoperative lengths of stay were identified between those who did or did not receive IFX.
In this cohort, surgical procedures in children and young adults treated with IFX were not associated with an increased number of complications or prolonged length of stay. Given that postoperative complications are infrequent in children, larger multicenter studies may be required to determine whether IFX therapy increases the risk of surgical complications in pediatric CD.
Background
Ileocecectomy is a mainstay surgical therapy for pediatric Crohn disease. However, there are few descriptions of single-incision laparoscopic ileocecectomy (SIL-I) in the pediatric ...population. This video describes our technique of the SIL-I, as well as our initial experience in pediatric patients with Crohn disease. Video runtime: 4:54.
Methods
Records of all patients with Crohn disease who underwent SIL-I between 2010 and 2012 were retrospectively reviewed. Variables including patient demographics, operative information, length of stay, and postoperative complications were collected
1
–
3
.
Results
Thirty-one SIL-I cases (mean patient age 17 ± 4 years) were reviewed. The average time from Crohn diagnosis to surgery was 4.8 ± 4.5 years. Seven patients (23 %) were below the 5th percentile for weight preoperatively. Three patients had undergone prior abdominal operation. There were no operations where an additional laparoscopic port was placed; however, one operation required extension of the umbilical incision beyond 3.5 cm in the setting of extensive interloop abscesses, dense adhesions and interloop fistulae. All anastomoses were stapled extracorporeally. The mean operative time was 3.8 ± 1.1 h. There were no intraoperative complications. Five postoperative complications were documented, including one superficial wound infection, two intra-abdominal abscesses (one within 30 days of the operation, one more than 3 months post-procedure), one peripherally inserted central catheter (PICC)-associated bacteremia, and one small bowel obstruction. Average postoperative length of stay was 7.1 ± 2.9 days, and median length of follow-up was 5.27 months.
Conclusions
This is the largest reported series of SIL-I in the pediatric surgery population. Our presented technique is safe, effective, and may be adopted by any pediatric surgeon with laparoscopic experience. Further studies are necessary to demonstrate both cost effectiveness and long-term outcomes of SIL-I versus conventional laparoscopic techniques.
Abstract Background Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, ...but few large series reports exist in the literature. Methods The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. Results We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. Conclusion Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.
Background. A common site for neonatal intestinal obstruction is the duodenum. Delayed establishment of enteral nutritional autonomy continues to challenge surgeons and, since early institution of ...nutritional support is critical in postoperative newborns, identification of patients likely to require alternative nutritional support may improve their outcomes. Therefore, we aimed to investigate risk factors leading to delayed establishment of full enteral nutrition in these patients. Methods. 87 patients who were surgically treated for intrinsic duodenal obstructions from 1998 to 2012 were reviewed. Variables were tested as potential risk factors. Median time to full enteral nutrition was estimated using the Kaplan-Meier method. Independent risk factors of delayed transition were identified using the multivariate Cox proportional hazards regression model. Results. Median time to transition to full enteral nutrition was 12 days (interquartile range: 9–17 days). Multivariate Cox analysis identified three significant risk factors for delayed enteral nutrition: gestational age (GA) ≤ 35 weeks ( P < . 001 ), congenital heart disease (CHD) ( P = . 02 ), and malrotation ( P = . 03 ). Conclusions. CHD and Prematurity are most commonly associated with delayed transition to full enteral nutrition. Thus, in these patients, supportive nutrition should strongly be considered pending enteral nutritional autonomy.
Abstract Background Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000s. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) ...and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC). Methods A total of 68 children underwent laparoscopic-assisted TPCs at our institution from June 2003 to February 2011. The patients ranged from 5 to 22 years of age. We progressively modified our surgical approach in positioning, equipment use, and operative technique. Results A total of 68 children underwent laparoscopic-assisted TPC within the 8-year time period. Two major complications occurred (2/68 = 3%) consisting of 1 duodenal injury and 1 small bowel injury. There were 6 minor complications (6/68 = 9%), including 5 stoma revisions and 1 port site hernia. There were no superficial wound infections. There were no reported cases of pouch fistulas, anastomotic breakdown, or neurovascular injuries. Conclusions Our surgical technique is safe and effective in treating children with UC.
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