Enhanced Recovery After Surgery In The Treatment Of Upper Digestive Tract Malformation

Part Ⅰ Enhanced recovery after surgery in correction of intestinal malrotation in neonatesObjective Enhanced recovery after surgery(ERAS)refers to the use of a series of optimization measures with evidence-based medical evidence during the perioperative period to reduce surgical stress and trauma,and to accelerate the recovery of patients and shorten the length of hospital stay.The core idea is to reduce the trauma and stress damage of patients.This technology is widely used in the field of colorectal surgery in adults,however,lacked in the field of pediatric surgery.Intestinal malrotation is the most common upper digestive tract malformations.This part of study is primarily desgined to evaluate the safety and efficacy of enhanced recovery for intestinal malrotation in neonates.Methods A prospective study was conducted for assessment of the safety and efficacy of enhanced recovery after surgery for intestinal malrotation.51 neonates aged from 1 day to 28 days with intestinal malrotation undergoing operations from January 2015 to March 2018 were prospectively summarized.The patients were divided into two groups: ERAS group(enhanced recovery after surgery;a transnasal placement of jejunal feeding tub in operation for early enteral nutrition after surgery,March2016 to March 2018,n =31)and control group(January 2015 to Febuary 2018,n=20)on admission.The intraoperative blood loss,operative time,preoperative hospital stay,time to first defecation,time to initial enteral nutrition,time to total enteral nutrition time,stress after operation,and complications were compared.Postoperative recovery was followed-up for 6 months.Results There were no significant difference in intraoperative blood loss between ERAS and control group(18.77±3.57 ml VS18.90±3.48 ml P>0.05).The preoperative hospital stay was shorter in ERAS group than that in control group(1.78±0.33 d VS2.28±0.74 d,P<0.05).The operative time was longer in ERAS group than that in control group(139.16±7.03 min VS 74.30±5.92 min,P<0.05).The time to first defecation,initial and total enteral nutrition were earlier in ERAS group than that in control group(1.80±0.33 d VS 2.25±0.54 d,P<0.05;1.32±0.31 d VS 4.42±0.82 d,P<0.05;7.55±0.66 d VS 8.40±0.75 d,P<0.05).The stress index including CRP,IL-6 and Cortisol were lower in ERAS group than that in control group(9.29±1.81mg/L VS 20.45±4.31mg/L,P<0.05;2.76±0.21pg/L VS 7.10±1.02pg/L,P<0.05;86.75±32.77nmol/L VS 156.75±35.59nmol/L,P<0.05).Compared the postoperative complications between the two groups,There was no recurrence of volvulus in the two groups,and no incision infection in ERAS group.However,there was no difference in the respiratory tract infection and diarrhea between the two groups(9.6% VS 15%,P>0.05;6.45% VS 10%,P>0.05).There was no re-hospitalization after operation by 6 months follow-up.Conclusion ERAS was safe to neonates with intestinal malrotation,which could reduce the stress effect and enhance early recovery after surgery.PartⅡ Plasma miRNAs in congenital intestinal malrotationObjective Intestinal malrotation(IM)in newborns might require urgent surgical treatment,especially in presence of volvulus,and therefore early-stage diagnosis is crucial.We sought to identify plasma micro RNAs(miRNAs)whose expressions are altered in intestinal malrotation and to test the specificity and sensitivity of utilizing them to diagnose intestinal malrotation.Methods High-throughput Illumina sequencing was used in 3 couple of IM(Symptomatic IM without vovulus)cases and control cases and carried out to reveal a profile of dysregulated plasma miRNAs.Real-time quantitative polymerase chain reaction and ROC analysis were adopted to further validate the results in 10 couple of IM(Symptomatic IM without vovulus)cases and control cases.Bioinformatics analyses were also performed to investigate the molecular functions of dysregulated plasma miRNAs in intestinal malrotation.Results A profile of 28 dysregulated plasma miRNAs was unveiled and 9 continued to exhibit markedly altered expression during verification,of which 3 showed great potential to work as novel early-stage,non-invasive signature for intestinal malrotation screening.Bioinformatics analyses demonstrated that the dysregulated miRNAs were mainly involved in metal ion transmembrane transporter activity,calcium-dependent protein binding,and they might be related to the endocytosis pathway.Conclusion We disclosed the potential roles of plasma miRNAs in intestinal malrotation and identified significantly and steadily dysregulated miRNAs in patients’ plasma,which have the potential to function as biomarkers and promote early diagnosis of intestinal malrotation.Part Ⅲ Enhanced recovery after surgery in the treatment of annular pancreasObjective Annular pancreas is one of the common upper digestive tract malformation.The procedures of operations were more complex than that in intestinal malrotaion.This part of study is primarily desgined to evaluate the safety and efficacy of enhanced recovery after surgery in the minimally invasive treatment of annular pancreas.Methods Sixty six neonates aged from 1 day to 28 days with annular pancreas undergoing operations from January 2011 to June 2017 were retrospectively summarized.The patients were divided into two groups: enhanced recovery after surgery group(ERAS group,n =31)and control group(n=35).The postoperative C-reactive protein level,initial defecation time,initial enteral nutrition time,total enteral nutrition time,total hospitalization time were compared between the two groups.The postoperative complications(anastomotic leakage,wound infection,respiratory infection,adhesion)were also compared between the two groups.Nutritional Status(weight,albumin,prealbumin)was assessed 1 week after operation between the two groups.Results There were no significant differences in operative age,weight,male/female,albumin,prealbumin between ERAS and control group(3.60±2.20 d VS 3.32±2.18 d,P>0.05;2.53±0.39 kg VS 2.47±0.35 kg,,P>0.05;20/15 VS 18/13,P>0.05;35.55±1.22 g/L VS 35.50±1.60 g/L,P>0.05;0.10±0.015 g/L VS 0.10±0.016 g/L,P>0.05).The postoperative CRP level was lower in ERAS group than that in control group(8.74±2.62mg/L VS 15.26±5.36 mg/L,P<0.05).The initial defecation time,initial enteral nutrition time and total enteral nutrition time were earlier in ERAS group than that in control group(1.81±0.60 d VS 3.03±0.62 d,P<0.05;4.06±0.51 d VS 6.80±0.90 d,P<0.05;8.45±0.99 d VS 11.4±0.74,P<0.05).The hospital stay was shorter in ERAS group than that in control group(10.77±1.02 d VS 14.03±1.27 d,P<0.05).The rate of respiratory infection and incision infection were lower in ERAS group than that in control group(6.5% VS 24.0%,P<0.05;3.2% VS 22.9%,P<0.05)and no anastomosis leakage was found in the two groups.The incidence of postoperative adhesive intestinal obstruction were lower in ERAS group than those in control group(3.2% VS 25.7%,P<0.05).The serum albumin 1 week after operation was higher in ERAS group than that in control group(34.4±0.80 g/L VS 34.7±0.76 g/L,P<0.05).There were no difference in weight and prealbumin 1 week after operation between the two groups(2.52±0.39 kg VS 2.46±0.35,P>0.05;0.10±0.014g/L VS 0.10±0.016,P>0.05).Conclusion Enhanced recovery after surgery may be safe and appropriate for the treatment of annular pancreas,which could reduce the stress and enhance the recovery.Part IV Enhanced recovery after surgery in the treatment of high jejunal ⅢB atresia in neonatesObjective High jejunal ⅢB atresia is the most complicated upper digestive tract malformation in neonates and the procedures of operations are more complex than that in intestinal malrotations and annular pancreas.This part study is primarily desgined to evaluate the safety and efficacy of enhanced recovery after surgery in the treatment of high jejunal apple-peel atresia.Methods Between January 2013 and December 2017,a total of 51 children with high jejunal ⅢB atresia underwent primary anastomosis,and were divided into the following 2 groups: ERAS group(group A [n=22]);and control group(group B [n=29]).The operative time,time-to-first defecation,time-to-first enteral nutrition,time-to-total enteral nutrition,and length of post-operative hospital stay were reviewed for assessment of intestinal function recovery.Patient weight,albumin and pre-albumin levels before and 2 weeks post-operatively were compared in the 2 groups to evaluate nutrition status.The direct bilirubin,alanine aminotransferase(ALT),and aspartate aminotransferase(AST)levels,and the obstruction of anastomotic stoma,sepsis,diarrhea,respiratory tract infection,and intestinal perforation rates were compared for assessment of complications.Results Four patients were discharged 2 days post-operatively for unknown reasons and lost to follow-up and 1 patient in group B died due to septic shock secondary to necrosis of the distal intestine identified at the time of re-operation;these patients were excluded from statistical analyses.The operative time was longer in group A than group B(167.27±7.67 min VS 129.17±4.58 min,P<0.05).The time-to-first defecation,time-to-first enteral nutrition,and time-to-total enteral nutrition were earlier in group A than group B(4.09±0.81 VS 6.17±0.70 d,2.68±0.48 VS 17.5±2.81 d,and 20.36±2.13 VS 25.58±2.24 d,respectively;P<0.05).The length of post-operative hospital stay was shorter in group A than group B 25.09±2.24 VS 31.50±5.86 d,P<0.05).There were no differences in patient weight and serum albumin and pre-albumin levels before and 2 weeks post-operatively between the 2 groups(2.48±0.38 VS 2.39±0.35 kg and 2.51±0.38 VS 2.42±0.35 kg,35.43±1.41 VS 35.42±1.78 g/L and 31.73±1.45 VS 31.75±2.09 g/L,and 0.09±0.01 VS 0.10±0.02 g/L and 0.09±0.01 VS 0.09±0.01 g/L,respectively;P>0.05).The anastomotic stoma obstruction and sepsis rates were significantly lower in group A than group B(0% VS 25% and 0% VS 25%,respectively;P<0.05).The direct bilirubin level post-operatively was lower in group A than group B(20.00±9.89 VS 31.00±11.41 umol/L,respectively;P<0.05).There were no differences in the ALT and AST levels and the diarrhea and respiratory tract infection rates between the 2 groups(15.73±5.20 VS 17.41±4.91 U/L and 20.27±5.36 VS 22.54±4.70 U/L,and 36.3% vs.33.3% and 18.2% VS 16.6%,respectively;P>0.05).No intestinal perforations occurred in the two groups.Conclusion Enhanced recovery after surgery may be safe and appropriate for the treatment of high jejunal ⅢB atresia,which could enhance the recovery of intestinal function post-operatively,shorten the length of the post-operative hospital stay,and reduce the rate of complications,such as anastomotic stoma obstruction,sepsis,and cholestasis.