Investigations, management and outcome of neonates presenting with distal intestinal obstruction: challenging the need for contrast enemas.

PURPOSE: To characterise the investigations, management and ultimate diagnosis of neonates with distal intestinal obstruction. METHODS: Retrospective review of term (> 37 weeks) neonates with admission diagnosis of distal intestinal obstruction over 10 years (2012-2022). Patient pathways were identified and associations between presentations, response to treatments and outcome investigated. RESULTS: A total of 124 neonates were identified and all included. Initial management was colonic irrigation in 108, contrast enema in 4, and laparotomy in 12. Of those responding to irrigations none underwent contrast enema. Ultimately, 22 neonates proceeded to laparotomy. Overall, 106 had a suction rectal biopsy and 41 had genetic testing for cystic fibrosis. Final diagnosis was Hirschsprung disease (HD) in 67, meconium ileus with cystic fibrosis (CF) in 9, meconium plug syndrome in 19 (including 3 with CF), intestinal atresia in 10 and no formal diagnosis in 17. Median length of neonatal unit stay was 11 days (7-19). CONCLUSIONS: Initial management of neonates with distal bowel obstruction should be colonic irrigation since this is therapeutic in the majority and significantly reduces the need for contrast enema. These infants should all have suction rectal biopsy to investigate for HD unless another diagnosis is evident. If a meconium plug is passed, testing for CF is recommended. Evaluation and therapy are multimodal and time consuming, placing burden on resources and families.

Retained intravascular catheter fragment at removal of implantable vascular access device: Incidence, risk factors, and outcomes.

BACKGROUND: Retained intravascular catheter fragments (RICF) are a rare complication of implantable vascular access device (IVAD) removal for which there is limited understanding of aetiology. There is a varied approach to management among the currently published literature. AIMS: The aim of this study was to establish incidence, risk factors, and outcomes for RICF after attempted removal of IVADs. METHODS: A single institution retrospective review was undertaken of individuals ≤ 25 years undergoing removal of IVADs from October 2014 to June 2019. Risk factors for RICF were explored using univariable logistic and Cox regression analysis. RESULTS: Six cases of RICF were identified among 654 line removal episodes (0.92% (95% CI 0.37-2%)) in patients aged 6-17 years (median 11, IQR 6-15 years). The main risk factor for RICF at removal was found to be line duration (OR 3.5/year, 95% CI 2.1-5.84, p < 0.0001). No RICFs occurred in lines indwelling for < 3 years. Five children with RICF ≤ 16 years were discussed with a paediatric cardiothoracic centre, and all were left in situ with 4 remaining asymptomatic. One had the fragment tip extruded through a wound, which required trimming. The other (17 years of age) developed an infected sinus for which partial removal with open excision followed by full removal with endovascular snare retrieval was performed by the adult vascular surgeons. CONCLUSION: IVADs in-situ for longer than a three-year period are at greatest risk of RICF upon removal. Management with transfixion of line fragments to surrounding muscle seems prudent while invasive attempts at retrieval appear unwarranted.

Management of post appendicectomy intra-abdominal collections: A volumetric cut off for drainage?

BACKGROUND: Intra-abdominal collections (IAC) are a common complication following appendicectomy, one of the most commonly performed emergency abdominal procedures in childhood. The option to drain a collection is frequently available but not always required. AIM: The aim of this study was to compare the outcomes of medically and procedurally-managed post appendicectomy IACs and suggest a method of standardising the need for intervention. METHODS: A single centre, retrospective review of children aged ≤ 16 years presenting between 2014 and 2019 was performed. Patient demographics, management, and outcome data were collected. IAC volume and surface area were calculated assuming a prolate spheroid or true ellipsoid depending on the number of dimensions reported. RESULTS: 60 patients (18%) of 334 patients developed an IAC post appendicectomy. Medical management was undertaken in 44 (73%), drainage in 12 (20%), and surgical washout in 4 (7%). Collection size was associated with failure of medical management: maximum diameter (p = 0.028), volume (p = 0.002), and surface area (p = 0.001). Collections with a volume of 2 ml/kg were significantly less likely to fail medical management than larger collections (0/33 vs 6/11; p < 0.0001). DISCUSSION: Not all post appendicectomy IACs require drainage. The relationship between collection volume and need for drainage is more closely assessed using a volume calculation rather than a single dimension measurement, particularly when adjusted for weight of the child. A cut off of 2 ml/kg appears to be a good objective measure for intervention and provides a communication tool for discussion amongst the multidisciplinary team. Prospectively collected multicentre data on this subject would be timely. LEVEL OF EVIDENCE: III.

Diagnosis, management and outcome of splenic torsion; a systematic review of published studies.

INTRODUCTION: Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management. METHODS: A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution. RESULTS: 408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis. DISCUSSION: Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

Unexpected tunnelled central venous access demise: a single institutional study from the UK.

PURPOSE: To explore the factors involved in the demise of tunnelled central vascular access devices (CVADs) in children and describe patterns of failure. METHODS: A retrospective study including children under 16 years of age undergoing CVAD insertion in a tertiary centre between October 2014 and December 2019. The Kaplan-Meier estimator was used to study CVAD survival and piecewise exponential curves to approximate hazard rates. Related factors were analysed using multivariable regression. RESULTS: Totally, 684 CVADs were inserted in 499 children. Devices were in situ for 213,821 days (median 244.5). Of those, 261 CVADs (38.2%) failed prematurely; 176 (67%) required replacement. Tunnelled external lines (TELs) failed more frequently than totally implantable devices (p < 0.005).TEL displacement occurred in two high-risk phases, falling to baseline after 90 days. Low age at device insertion and open placement were strongly associated with an increased failure rate. Previous CVAD failure did not increase subsequent failure rate. Premature failure increased procedural cost by £153,949 per year. CONCLUSIONS: TIDs should be placed in preference to TELs where appropriate. TELs are at highest risk of displacement for 90 days and must be well secured for this duration. Meticulous line care offers significant potential cost savings by reducing line replacements. LEVEL OF EVIDENCE: Level III.

Comorbidities and Ventricular Dysfunction Drive Excess Mid-Term Morbidity in an Indigenous Australian Coronary Revascularisation Cohort.

BACKGROUND: There is a paucity of data in regards to longer term morbidity outcomes in Indigenous Australian patients undergoing coronary artery bypass grafting (CABG). No comparative data on re-infarction, stroke or reintervention rates exist. Outcome data following percutaneous coronary intervention (PCI) is also extremely limited. Addressing this gap in knowledge forms the major aim of our study. METHODS: This was a single centre cohort study conducted at the Townsville Hospital, Australia which provides tertiary adult cardiac surgical services to the northern parts of the state of Queensland. It incorporated consecutive patients (n=350) undergoing isolated CABG procedures, 2008-2010, 20.9% (73/350) of whom were Indigenous Australians. The main outcome measures were major adverse cardiac or cerebrovascular events (MACCE) at mid-term follow-up (mean 38.9 months). RESULTS: The incidence of MACCE among Indigenous Australian patients was approximately twice that of non-Indigenous patients at mid-term follow-up (36.7% vs. 18.6%; p=0.005; OR 2.525 (1.291-4.880)). Following adjustment for preoperative and operative variables, Indigenous Australian status itself was not significantly associated with MACCE (AOR 1.578 (0.637-3.910)). Significant associations with MACCE included renal impairment (AOR 2.198 (1.010-4.783)) and moderate-severe left ventricular impairment (AOR 3.697 (1.820-7.508)). An association between diabetes and MACCE failed to reach statistical significance (AOR 1.812 (0.941-3.490)). CONCLUSIONS: Indigenous Australians undergoing CABG suffer an excess of MACCE when followed-up in the longer term. High rates of comorbidities in the Indigenous Australian population likely play an aetiological role.

Recurrent left ventricular thrombus in Crohn's disease: a rare presentation.

A 40-year-old man with Crohn's disease was found to have recurrence of a large left ventricular mass on echocardiography during workup for stricturoplasty. He presented with left limb emboli. He had been diagnosed with a left ventricular thrombus 2 years earlier, with multiple cerebral and peripheral emboli, and underwent surgery. We carried out redo surgery, and histology revealed organized thrombus. We discuss the management of this complex case.