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Background: The Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure., Methods: A retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL)., Results: A total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10-50), operative time was 2.3 h (IQR, 1.8-2.8), and hospital length of stay was 2 days (IQR, 2-3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25-13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition., Conclusion: The laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2024. Published by Elsevier Inc.)

Background: Pediatric intestinal rehabilitation (PIR) programs are associated with improved outcomes in children with intestinal failure but remain heterogeneous nationally. This study characterizes PIR program components to aid those seeking to establish or expand a program., Methods: Members of the Children's Hospital Association reporting a PIR program to the US News and World Report completed a 14-item questionnaire using the Qualtrics Online Survey Software. Programs were categorized as small or large (≤50 vs >50 patients) and new or established (≤10 vs >10 years)., Results: Seventy-one programs were identified and 61 surveys were returned for a response rate of 86%. Majority of programs had gastroenterology, surgery, nutrition, nursing, and social work services involved. Large programs (n = 34; 59%) were more likely to serve as referral centers; have greater participation by nursing, social work, and primary care; have more dedicated time by gastroenterology, surgery, nursing, nutrition, and social work; have more frequent meetings; and have various funding sources (P < .05)., Conclusion: Critical components of a PIR program include gastroenterology, surgery, and nutrition services with strong nursing and social work support. These data document the components of modern PIR programs, though further studies on the relationship between program structure and patient outcomes are warranted., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Impact Statement: Localization of a specific subtype of the muscarinic acetylcholine receptor in the crypt stem cell compartment suggests a critical role in intestinal mucosal homeostasis. Here we demonstrate the localization of the M1 muscarinic acetylcholine receptor to the stem cell compartment and demonstrate increase morphometric and proliferative parameters when this is stimulated in vivo. These data provide novel information about this complex signaling microenvironment and offer potential future therapeutic targets for future study.

Evidence supports index cholecystectomy as the quality of care for patients admitted with acute cholecystitis. We sought to examine the role of hospital safety-net status on whether patients received appropriate index procedures for cholecystitis. The National Inpatient Sample was queried for patients with acute cholecystitis. Proportion of Medicaid and uninsured discharges were used to define safety-net hospitals (SNHs). Multivariate logistic regression was used to calculate associations between the frequency of index cholecystectomy and prolonged length of stay (LOS), and the effect of SNH designation. SNHs and non-SNHs had similar rates of index cholecystectomy in all geographic regions, except in the northeast, where the likelihood of having an index cholecystectomy was lower at SNHs. Patients at SNHs had longer LOS for acute cholecystitis, regardless of index or delayed cholecystectomy. When controlling for insurance status, patients at SNHs had longer LOS than those at non-SNHs. There was also increased LOS in SNHs in the Midwest, in urban hospitals, and in large hospitals. Our data showed no difference in the frequency of index cholecystectomy overall between SNHs and non-SNHs, except in the northeast. The variability and increased LOS at SNHs highlight potential opportunities to improve quality and decrease cost of care at our most vulnerable hospitals.

Objective: Previous studies reveal a correlation between surgical volume and outcomes; thus, a similar relationship likely exists between trainee operative volume and technical competence. While routine hepatobiliary surgery is commonplace, trainee exposure to the more advanced procedures may be lacking. We hypothesize that experience in complex hepatobiliary procedures may be deficient both during general surgery residency and pediatric surgery fellowship training., Design: Case log data from the ACGME were queried for general surgery residents (2000-2017) and pediatric surgery fellows (2004-2017). Laparoscopic cholecystectomy was considered a routine hepatobiliary procedure for both specialties. For general surgery, hepatic lobectomy/segmentectomy and choledochoenteric anastomosis were considered complex and for pediatric surgery, hepatic lobectomy, biliary atresia and choledochal cyst procedures were considered complex., Setting: Publicly available case log data from the ACGME., Participants: General surgery residents and pediatric surgery fellows at ACGME-accredited training programs., Results: The number of trainees increased over the study period for both groups. Mean case volumes for laparoscopic cholecystectomy increased by 36% in surgery graduates and by 114% in pediatric surgery graduates. In surgery, the mean volumes for choledochoenteric anastomosis procedures decreased by 53% from 3.0 to 1.4 procedures/year with increasing variability in trainee experience. Volumes for hepatic lobectomy/segmentectomy increased by 68% from 3.4 to 5.7 procedures/year with decreasing variability. In pediatric surgery, case volumes for complex procedures were low (mean <4/year), highly variable among trainees, and appear unchanged between 2004 and 2017. In every year analyzed, at least 1 pediatric surgery trainee reported doing 0 cases in one of these complex categories., Conclusions: Case logs suggest that the volume of complex hepatobiliary surgery remains low and highly variable in both disciplines with some trainees obtaining minimal or no exposure to certain cases. The relationship between these trends and the development of competency is worthy of further study., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Enteric serotonin may function as a mucosal growth factor. Previous work demonstrated increased crypt cell proliferation and intestinal mucosal surface area with potentiation of serotonin. While an indirect mechanism was postulated to explain these effects, the presence of 5-HT4 receptors on enterocytes raises the possibility of a direct action of serotonin. We hypothesized that a 5-HT4 specific agonist, prucalopride, would stimulate intestinal mucosal growth and enhance absorptive function in the murine small intestine., Methods: Adult wild-type mice were treated parenterally with prucalopride for 14 days via surgically implanted osmotic pumps. In vivo D-xylose absorption was assessed by oral gavage and serum D-xylose measurements. On day 14, glucose absorption was assessed by instilling a glucose solution into isolated segments of small intestine. The bowel was harvested and examined for morphologic parameters and crypt cell proliferation., Results: Villus height, crypt depth, and crypt proliferation were significantly increased in the distal small bowel of prucalopride-treated mice compared with control animals. Crypt depth was also increased in the proximal and middle small intestine in treated mice. There was no difference in D-xylose absorption throughout the study period; however, glucose absorption was significantly increased in the distal small intestine of prucalopride-treated mice., Conclusion: Parenteral administration of the 5-HT4 receptor specific agonist, prucalopride, results in morphologic and functional changes in the murine small intestine that are most prominent in the distal small bowel. While further studies are necessary to delineate the mechanism, it is plausible that the effects are mediated by 5-HT4 receptors on enterocytes.

Background: Abstracts presented at the American Academy of Pediatrics Section on Surgery (AAP) and American Pediatric Surgical Association (APSA) meetings can be taken as a reasonable representation of academic activity in pediatric surgery. We sought to assess ongoing trends in pediatric surgical research by analyzing the scientific content of each association's yearly meeting., Methods: Abstracts presented at AAP and APSA between 2009 and 2013 were identified from the final printed programs (n = 910). Video abstracts (n = 34) were excluded. Collected data included title, authors, classification (basic science/clinical), presentation type (podium/poster), and topic. Publication as a journal article was determined using the abstract title/authors in a PubMed search. Journal impact factors were recorded for each journal and a composite impact factor (CIF) was calculated by dividing the sum of impact factors by the published articles per meeting., Results: Number of abstracts presented, percentage published, abstract classifications, and presentation type remained consistent over the study period. The AAP meetings accepted a higher percentage of clinical abstracts: AAP 72.3 ± 3.4% versus APSA 65.9 ± 1.3%. The five most popular topics at both meetings were oncology, congenital diaphragmatic hernia, necrotizing enterocolitis, trauma, and appendicitis. The publication rate for clinical and basic science abstracts did not vary significantly over the study period, whereas CIFs were higher for basic science publications nearly every year. The percentage of podium abstracts published was significantly greater than poster abstracts, but no statistical difference in CIF was seen between podium- and poster-associated publications., Conclusions: Abstracts accepted and presented at the two major pediatric surgical specialty meetings more commonly involve clinical studies with a trend away from basic science. Despite this, basic science abstracts tended to be published in higher impact journals. This study attempts to quantify the quality of pediatric surgical research and serves as a baseline for future comparison., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Enteric serotonin influences intestinal homeostasis and functions as a mucosal growth factor. Previously, we demonstrated increased mucosal surface area and enhanced crypt cell proliferation in serotonin reuptake transporter (SERT)-deficient mice. Therefore, we hypothesized that serotonin-mediated mucosal growth would also result in enhanced carbohydrate and lipid absorption., Material and Methods: Wild-type C57Bl/6 (WT) and SERT-knockout (SERTKO) mice were fasted then gavaged with D-xylose or boron-dipyrromethene (BODIPY) FL-C12 medium-chain fatty acid analog. Serum D-xylose and BODIPY concentrations were serially measured from blood drawn at 30 to 360 min post-gavage. Small intestine was harvested from both groups for comparison of morphometric parameters. Area under the curve of plotted graphs was calculated, and means were compared with Student's t-test to a significance of p < 0.05., Results: Villus height and crypt depth were significantly greater in the middle and distal small intestine of SERTKO animals compared to WT. Overall absorption of D-xylose and BODIPY was greater in SERTKO animals compared to WT animals. Absorption of D-xylose was persistently elevated in SERTKO animals, while there was an initial delay in BODIPY absorption followed by a sustained and significantly greater absorption in SERTKO animals at 60-360 min after gavage., Conclusion: Potentiation of serotonin signaling in SERTKO mice results in small intestinal mucosal growth and enhanced carbohydrate and fat absorption in vivo. These functional increases support the concept of targeting the serotonin signaling system to augment intestinal adaptation in the setting of intestinal failure., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Plasma citrulline is a nonessential amino acid synthesized almost exclusively by enterocytes of the small intestine. Correlation between post-operative plasma citrulline levels and remnant small bowel mass and function has led to its use as a simple biomarker of functional intestinal mass in adults and children, with a proposed prognostic value for achieving enteral autonomy in the setting of intestinal failure. While it is standard to measure fasting levels in humans, the optimal timing of blood draws in relation to food intake and time of day has not been standardized and is poorly studied in animal models. We hypothesize that serum citrulline levels vary both throughout the day and with relation to food intake in mice., Methods: Serum citrulline levels were measured from 12 C57BL/6 mice (6 - 9 weeks old) in the mornings and evenings, either after ad libitum food intake or after 8 - 12 h of access to water only. Blood draws for each experimental set-up were performed 1 week apart according to our Institutional Animal Care and Use Committee (IACUC) guidelines for acceptable blood collection volumes for survival procedures. At the end of the experiment, mice were euthanized and small intestine was harvested for morphometric measurements. Group means were compared using Student's t -test with significance assumed for P < 0.05., Results: After withholding chow for 8 - 12 h, serum citrulline levels were significantly greater in the morning compared to levels drawn in the evening. When mice were allowed ad libitum chow, there was no significant difference in serum citrulline levels drawn in the morning compared to the evening. There was no difference detected in villus height across the different experimental conditions., Conclusions: Serum citrulline levels exhibit circadian variation and fluctuations in relation to food intake in mice, without apparent concurrent changes in enterocyte mass. There was no diurnal variation of serum citrulline levels in fed mice whereas fasted mice had significantly higher levels of serum citrulline in the morning compared to the evening. These findings underscore the paramount importance of consistent sample collection strategies in the setting of translational research.

Background: Biliary atresia (BA) causes progressive fibrosis and obliteration of the biliary tree, resulting in bile stasis and eventual liver dysfunction. It affects 1 in 10,000-18,000 infants, and if left untreated, universally leads to liver failure. The Kasai hepatoportoenterostomy (KPE) was developed as an effective surgical therapy for BA and can restore bile drainage into the intestine. Traditionally, the KPE procedure extra-corporealizes the liver to expose the portal plate. Here, we describe modifications to the procedure via a smaller incision in which the liver remains within the abdominal cavity and we compare the outcomes of this technique to previous institutional outcomes and to contemporary international series., Materials and Methods: We identified all patients who underwent KPE for BA at a single institution between 1994 and 2012. Patient outcomes after the modified KPE performed from 2004 to 2012 were compared to data from infants who underwent the traditional KPE from 1994 to 2003., Results: Ninety-nine patients were identified. Fifty-two were in the traditional KPE group and 47 in the modified KPE group. There was no difference in mean age at surgery. Median follow-up was 64 months (traditional KPE) and 46 months (modified KPE). The rate of native liver survival (39.1% vs 48.5%), overall survival (89.2% vs 97.8%), liver transplant occurring under one year of age (36.5% vs 40.4%) and median time to liver transplant (188 vs 172 days) were not statistically different between groups (p > 0.05 for all comparisons). The results of the modified KPE compared favorably to published outcomes., Conclusion: The described modifications to the KPE appear to yield equivalent outcomes when compared to the traditional KPE procedure and compare well with published outcomes in the literature. It is possible that the procedure described here results in less scarring and technically easier liver transplant procedures., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The purpose of our analysis was to assess the effects of pulmonary hypertension (PH) on clinical outcomes of patients undergoing laparoscopic procedures. Pulmonary hypertension alters physiologic patterns that has the potential to complicate laparoscopic procedures, however, an in-depth analysis evaluating survival outcomes, complications, and associated comorbidities has not been done before. Data from the National Inpatient Survey were used to identify 179,663 patients without PH and 1453 patients with PH undergoing laparoscopic procedures from the years 2003-2013. In patients with pulmonary hypertension, the presence of the following comorbidities, congestive heart failure (OR 3.56) diabetes with chronic complications (OR 3.74) fluid and electrolyte disorders (OR 7.34) metastatic cancer (OR 14.42) and peripheral vascular disease (OR 3.12) increased in-patient mortality. In regards to post-operative complications, patients with PH were more likely to have cardiac complications defined as cardiac arrest, cardiac insufficiency, cardiorespiratory failure, or heart failure (OR 3.74). Patients with PH were also more likely to develop iatrogenic pneumothorax (OR 4.13) iatrogenic pulmonary embolism (OR 7.65) and post-operative urinary complications (OR 1.92). Overall, the comorbidity with the highest association with in-patient mortality was metastatic cancer and of all complications, patients with PH were most likely to develop iatrogenic pulmonary embolism. Preparing for these adversities, notably in patients with certain associated conditions has the potential to improve patient outcome.

Background  The burden of frail patients undergoing emergency general surgery (EGS) is increasing rapidly and this population is particularly susceptible to postoperative cardiopulmonary complications and mortality. We aimed to determine the association between frailty, as defined by the previously described modified frailty index (mFI), and postoperative respiratory complications (unplanned reintubation, pneumonia, and prolonged ventilation), cardiac complications (myocardial infarction and cardiac arrest), and mortality. We also sought to identify the most significant determinants of frailty in the highest risk patients based on the specific variables comprising the mFI. Methods  We performed a retrospective observational analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Files from 2005 to 2015 identified 132,765 inpatients who underwent EGS. mFI scores were calculated for each patient. The effect of increasing frailty on unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality was evaluated using bivariate analysis. Multivariable logistic regression was used to compare mFI with additional predictor variables including race, gender, physical status as defined by the American Society of Anesthesiologists, disseminated cancer, renal failure, smoking status, sepsis, wound presence/classification, dyspnea, and previous ventilator dependence. Results  Unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality were significantly associated with frailty, and the odds of each postoperative complication increased with increasing mFI score. Of the frailest patients (mFI ≥3) that experienced cardiopulmonary complications or mortality, the variables of the mFI that contributed most to frailty were hypertension requiring medication and functional status before surgery. Conclusions  A higher mFI score is associated with increased odds of postoperative cardiopulmonary complications and mortality in the EGS population. Specific variables of the mFI can also provide valuable information for assessing odds in the frailest patients undergoing EGS.

Background: Socioeconomic factors such as race, insurance, and income quartiles have been identified as independent risk factors in emergency general surgery (EGS), but this impact has not been studied over time. We sought to identify trends in disparities in EGS-related operative mortality over a 20-y period., Methods: The National Inpatient Sample was used to identify patient encounters coded for EGS in 1993, 2003, and 2013. Logistic regression models were used to examine the adjusted relationship between race, primary payer status, and median income quartiles and in-hospital mortality after adjusting for patients' age, gender, Elixhauser comorbidity score, and hospital region, size, and location-cum-teaching status., Results: We identified 391,040 patient encounters. In 1993, Black race was associated with higher odds of in-hospital mortality (odds ratio [95% confidence interval]: 1.35 [1.20-1.53]) than White race, although this difference dissipated in subsequent years. Medicare, Medicaid, and underinsured patients had a higher odds of mortality than those with private insurance for the entire 20-y period; only the disparity in the underinsured decreased over time (1993, 1.63 [1.35-1.98]; 2013, 1.41 [1.20-1.67]). In 2003 (1.23 [1.10-1.38]) and 2013 (1.23 [1.11-1.37]), patients from the lowest income quartile were more likely to die after EGS than patients from the highest income quartile., Conclusions: Socioeconomic disparities in EGS-related operative morality followed inconsistent trends. Over time, while gaps in in-hospital mortality among Blacks and Whites have narrowed, disparities among patients belonging to lowest income quartile have worsened. Medicare and Medicaid beneficiaries continued to experience higher odds of in-hospital mortality relative to those with private insurance., (Copyright © 2017 Elsevier Inc. All rights reserved.)