"Surgery is indicated only for selected patients with any one of three conditions: (1) when the absorptive surface area is definitely too small to allow enteral feeding; (2) when severe dysmotility in grossly dilated loops entails stagnation of chyme; and (3) when intestinal transit time is too fast to allow sufficient absorption of nutrients. In the first group of patients, intestinal transplantation is the mainstay of surgical therapy. In the second group, peristalsis can be improved by intestinal tapering or tapering and lengthening. In the third group, antiperistaltic segments, colonic interposition, intestinal valves, and/or artificial invagination have been used in selected patients."

"Tapering is indicated in patients with sufficient intestinal length but severely dilated small bowel with impaired propulsive peristalsis. The intestinal content in the enlarged intestinal loops causes bacterial overgrowth, inflammation, and bacterial translocation with recurrent sepsis. Grossly dilated loops can be primarily due to an intentionally limited resection of small bowel in patients with intestinal atresia, or they can be the result of the process of intestinal adaptation with subsequent dilatation of the intestinal tract."

"Resection of the jejunum is well tolerated owing to the enormous adaptive capacity of the ileum, the intact enterohepatic circulation of bile salts, and the preserved absorption of fat-soluble vitamins and vitamin B12. In contrast, if the entire ileum is lacking, absorption of nutrients is significantly more difficult because of the limited intestinal adaptation capacities of the jejunum. Nonabsorbed intestinal contents, including bile acids, spill over into the colon and may cause significant diarrhea. Furthermore, loss of the ileum leads to a reduction of the bile salt pool, malabsorption of fat and fat-soluble vitamins, and a vitamin B12 deficiency."

"The pathophysiological process that follows an extensive loss of small bowel is called intestinal adaptation. It includes (1) morphological changes leading to an increase of absorptive surface area, (2) functional changes resulting in augmentation of the absorptive capacity of the remaining enterocytes, and (3) increased intestinal diameter with a concomitant reduction of motility, thereby slowing down the intestinal transit time of chyme."

"The presence of intraluminal food is the most important driving force for intestinal adaptation. Enteral nutrients stimulate gastrointestinal secretions and hormones that are known to exert trophic effects on the mucosa. Recent evidence suggests that glucagon-like peptide 2, human growth hormone, epidermal growth factor, and insulin-like growth factor I may play an important role in the process of intestinal adaptation."

"These are usually found in the retrorectal space and do not communicate with the urinary tract. Cystic rectal duplications must be distinguished from cystic sacrococcygeal teratoma, tailgut cyst, and an anterior meningocele. When associated with an anorectal malformation and sacral anomalies, the cyst may be part of the Currarino syndrome. Rarely, a rectal duplication cyst presents as rectal prolapse in an infant.

"Imaging is a critical aspect of preoperative preparation. The choice of imaging is dictated by the site of the duplication, clinical urgency, and the potential for associated anomalies. Isolated small bowel duplications often require no preoperative investigations other than abdominal sonography, a plain abdominal radiograph and routine blood tests. Occasionally, a technetium-99m pertechnetate radionuclide scan is helpful in detecting heterotopic gastric mucosa. In contrast, thoracoabdominal lesions demand detailed radiologic imaging of mediastinal, abdominal, and spinal components. MRI and/or CT scans enable evaluation of the cranial and caudal extent of the cyst. Upper gastrointestinal contrast studies and endoscopy may be necessary in selected cases. The possibility of an additional intestinal duplication must be considered with foregut duplications. Magnetic resonance cholangiography or, in older children, endoscopic retrograde cholangiopancreatography (ERCP) are valuable in the assessment of pancreatic and selected duodenal duplications. Magnetic resonance angiography may assist in planning surgery for large retroperitoneal lesions. Pelvic duplications are best imaged by CT or MRI in conjunction with a contrast enema, fistulogram, endoscopy, and urinary tract sonography."

"The assistant should grasp and laterally retract the posterior wall of the stomach near the greater curvature to ensure no wall of the stomach is folded on itself causing four layers to be included in the staple line. This also prevents the sleeve from twisting as sequential firings take place, resulting in a spiral staple line."

Quote from "The SAGES Manual of Pediatric Minimally Invasive Surgery" by Danielle S. Walsh, Todd A. Ponsky, Nicholas E. Bruns -

"Anastomotic leakage and bleeding may present initially only as sustained tachycardia; therefore, the threshold for obtaining an oral and IV contrast-enhanced CT scan in the early postoperative period should be low."

Quote from "The SAGES Manual of Pediatric Minimally Invasive Surgery" by Danielle S. Walsh, Todd A. Ponsky, Nicholas E. Bruns -

"Bleeding tends to occur where dissection of the gastroepiploics began, and this area should be inspected prior to removal of ports. Sleeve leaks tend to occur proximally, where visualization of the last staple firing is difficult and the esophagus may be crossed."

"Patient selection is very important and should be a joint decision from a MDT consisting of paediatrician, surgeon, dietician and psychologist. Before decision-making, patients are thoroughly investigated to identify any underlying condition causing obesity, e.g. hypothyroidism or Prader-Willi syndrome (PWS). Investigations also look for any obesity-related co-morbidities. Blood investigations include full blood count, urea and electrolytes, liver function and metabolic profile to look for non-alcoholic hepatic steatosis or type 2 diabetes. A sleep study should also be performed to diagnose obstructive sleep apnoea. Apart from this, baseline anthropometric measurements, an ECG, echocardiogram, and ambulatory blood pressure monitoring are also performed."

Quote from "ESPES Manual of Pediatric Minimally Invasive Surgery" by Ciro Esposito, François Becmeur, Henri Steyaert, Philipp Szavay -

"When a patient has been deemed suitable for surgical intervention, a liver shrinking diet is recommended. It comprises of a 14-day period of high-protein, low-carbohydrate milkshake replacement for meals, which aims to reduce weight and size of the liver, making the laparoscopic access to the stomach easier."

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Regarding current treatment of annular pancreas by duodenoduodenostomy