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.
Conclusion While V-CLC may not full replicate a physical classroom experience, it provides a viable alternative during the COVID-19 pandemic. Successful application of this virtual collaborative pedagogy model to other different contexts will require bespoke adjustments for optimal adaptation to local conditions.
Background: Pediatric renal transplants can be technically challenging because of disparity in the recipient vessels and body cavity, and the adult donor vessels and organ mass respectively. Innovative technologies utilizing spatial reconstruction may be beneficial in preoperative planning for these patients. We present a case where three-dimensional (3D) reconstruction, and a mixed reality system were employed in preoperative planning as proof of concept. Methods: The recipient is an 18-year-old male patient with end-stage renal failure from Alport syndrome and steroid-resistant nephrotic syndrome. His small and slender stature (36.7 kg, 161.3 cm) and severe thoracoabdominal scoliosis (Cobb angle of >60°) raised concerns of potential limitations in space for retroperitoneal implantation and challenges in alignment with potentially tortuous and size-matched iliac vessels for vascular anastomoses. A computed tomography scan was hence performed for preoperative planning. The donor's (the mother) computed tomography scan of the kidneys was superimposed with that of the recipient utilizing Synapse 3D (Fujifilm Holdings America Corp.). Real-time holographic visualization was also accomplished utilizing HoloLens 2 (Microsoft Corp.). Results: Preoperative visualization of the 3D images and video confirmed that there was sufficient domain for a retroperitoneal implantation and planning of vascular anastomoses to the right common iliac artery and vein which were respectively 6 to 7 mm and 10 mm in caliber and relatively straight at the proposed site of anastomoses. The renal transplants proceeded as planned with a warm ischemic time of 44 minutes. There was brisk urine output on-table and preserved vascular patency and satisfactory waveforms on postoperative doppler ultrasound. Serum creatinine normalized by postoperative day 4. Conclusions: A combination of modern technologies (3D reconstruction and HoloLens2) are useful adjuncts in preoperative planning and performance of high-risk pediatric renal transplants. This technology may be also considered in the training, education, and intraoperative assistance of young pediatric renal transplant surgeons.
Background: Despite significantly improved outcomes in pediatric renal transplantation (RT), there remain challenges for children weighing 15 kg or less; with consequently higher risks of complications and graft loss. Especially for smaller pediatric recipients of adult-donor kidneys, we aim for optimal renal perfusion by emphasizing meticulous technique for vascular anastomoses; together with aggressive volume support in the living-donor and recipient. Methods: The medical records of 10 pediatric kidney recipients <15 kg at transplant (eight living-related donors) between 1989 and 2020 were retrospectively reviewed. Results: Overall, the median age and weight at transplant were 56.5 months (IQR, 44.8-68) and 12.9 kg (IQR, 12.2-14.2) respectively. There were nine children who received pretransplant dialysis over a median duration of 26 months (IQR, 13-40). The surgical approach was either transperitoneal (n=6) or retroperitoneal (n=4) with the vascular anastomoses being to the aorta/ inferior vena cava (n=7), common iliac vessels (n=2) or splenic vessels (n=1). One child developed early vascular thrombosis requiring graft nephrectomy (day 4). None of the remaining children developed delayed graft function. Delayed complications were BK virus nephropathy (n=1, progressive graft failure 6 months posttransplant requiring resumption of dialysis and eventual re-transplantation at age/weight of 79 months and 19.5 kg respectively) and ureteric stricture (n=1, requiring revision ureteroureterostomy at five years posttransplant). Graft survival at 1-year and 2-years was 90% and 80% overall; and was 100% and 87.5% for living-related grafts respectively. Nine children have functioning grafts to date; over a median follow-up period of 14 years (IQR,). The mean creatinine levels were 83.5±35.3 umol/L at last follow-up. Conclusions: Living-related kidney transplantation in children 15 kg or less may be safely performed in experienced pediatric centers with excellent short-term and long-term outcomes.
Paediatric living-donor liver and kidney transplantation during COVID-19LETTER TO THE EDITOR Dear Editor, The coronavirus disease 2019 (COVID-19) pandemic has impacted global healthcare including paediatric solid organ transplantation (SOT). We report our experience of resuming paediatric living-donor SOT during COVID-19, which took into account safety considerations for living donors, paediatric recipients and the transplant healthcare team. The US Centers for Disease Control and Prevention has categorised SOT recipients at high-risk for COVID-19. 1 During this period, transplantation programmes worldwide were either suspended or curtailed. 2,3 In Singapore, all non-urgent deceased-donor transplants were temporarily suspended; living-donor transplants could only proceed if medically urgent. 4,5 The paediatric solid organ transplant programme at the National University Centre for Organ Transplantation is a small but essential one. Since the start of the paediatric liver and kidney transplant programmes in 1991 and 1989, respectively, a total of 140 liver and 98 kidney transplants have been performed. Livingdonor transplantations account for nearly 86% of the paediatric liver transplants and 58% of the paediatric kidney transplants. 6 In the early years, the wait-list mortality for paediatric liver transplant was 15%. 7 However, with increasing availability of living donors, the wait-list mortality in the last decade is nearly zero. Particularly for children with acute liver failure or chronic end-stage liver disease, there would be no option for survival without liver transplant, unlike children with renal failure where dialysis is an option. At the time of the nationwide partial lockdown in Singapore known as the circuit breaker (7 April-1 June 2020), there were 22 paediatric patients with kidney failure on long-term dialysis, of whom 4 were on the waiting list for a deceased donor kidney transplant. However, unlike the severe acute respiratory syndrome in 2003, the COVID-19 pandemic was prolonged. 8 As the paediatric dialysis programme had only 4 dialysis nurses running the national programme, this was almost at full capacity. The mandatory requirement to split medical teams into 2 groups further aggravated the manpower shortage. Therefore, deferring fully worked-up living-related-donor kidney transplants for a prolonged duration would have added to the strain on the dialysis services. Further to the gradual and
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