Gastric pull-up by the retrosternal route for esophageal replacement: Feasibility in a limited-resource scenario.

OBJECTIVES: The authors herein report the results of esophageal replacement by gastric pull-up technique through the retrosternal route as an option for esophageal replacement in a resource-constrained setup. METHOD: Prospectively collected data upon twenty-two consecutive patients (male:female = 17:5) with mean age 24.9 months (7 months-12 years) and mean weight 7.9 kg (4.2-32 kg) who underwent retrosternal gastric pull-up for esophageal atresia (n = 18; 16 atresia with distal fistula & 2 pure atresia) and corrosive injuries to the esophagus (n = 4) over the past 8 years are presented. The management protocol and surgical technique have been described. Observations parameters included indication for esophageal replacement, age at surgery, sex of the child and other demographic details, clinical and operative findings, post-operative outcomes and follow-up details. RESULTS: Retrosternal gastric pull-up could be performed in all cases with no mortality or graft loss. Of 22, 20 cases were extubated on-table and 2 cases were extubated within 48 hours of surgery. Mean operative duration was 265 min (range: 175 min to 310 min) and blood loss was 115.3 ml (range: 80-400 ml). Dense vascular adhesions in the region of the esophageal hiatus were encountered in patients with abdominal esophagostomy (n = 4) which were probably related to the local dissection at the time of previous surgery. Minor anastomotic leak was observed in 8 of 22 patients which settled spontaneously over 21 days mean period (range: 18 to 31 days). Antegrade dilatation was required in 3 of 8 cases with minor leak. None of them required revision of anastomosis. Mean follow-up duration is 63 months (range: 11 months - 94 months). Weight gain after surgery was close to or beyond the 25th centile. Symptoms of dumping syndrome or GER were not observed in our cohort. CONCLUSION: Our data have demonstrated the safety and feasibility of esophageal replacement by gastric transposition through the retrosternal route in a resource-limited setup. No significant difference has been observed from the results and complications reported in literature for the same procedure. TYPE OF STUDY: Prospective observational study / treatment study. LEVEL OF EVIDENCE: Level III.

Primary anastomosis in difficult cases of type "C" esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome.

BACKGROUND: Surgical maneuvers for esophageal anastomosis in difficult cases of Gross type "C" esophageal atresia (EA) are challenging. The methods of early primary anastomosis are technically difficult and staged surgeries expose the child to repeated general anesthesia with problems of nursing care. We describe a simple method of partial disconnection of the lower esophagus from the fistula followed by approximation by an atraumatic microvascular clamp. The suitability of this method and its outcomes are discussed. METHODS: It was a prospective observational study that included 32 patients of type "C" EA between January 2014 and December 2016. Babies with birth weight more than 2 kg without cyanotic heart defects and requirement of intensive care were included. An early primary anastomosis using this technique was tried in all. A cervical esophagostomy with feeding gastrostomy was done where it was not possible. Analysis of the gap and post operative outcomes i.e. gastroesophageal reflux (GER), stricture, tracheomalacia, dysmotility, recurrence and survival were analyzed. RESULTS: The mean gap between esophageal ends was 4.3 cm. Primary anastomosis was possible in 26 (81.25%). Minor and major leak occurred in 3 (11.54%) and 1 (3.85%) patients respectively. Survival was 84.62% (22/26). All mortalities were early post operative. During mean follow up of 23.73 months (till December 2019), GER decreased from 63.64% (14/22) to 13.64% (3/22), partial stricture was seen in 18.18% (4/22), tracheomalacia in 36.36% (8/22) and dysmotility in 77.27% (17/22). There was no recurrence of fistula. Complications with this method did not show any significant difference as mentioned with other methods. CONCLUSION: This technique seems to be physiologically suitable as it enables anastomosis with minimal trauma to the esophageal ends. It is easy, reproducible and produces favorable outcomes comparable with other methods for difficult cases of type "C" esophageal atresia (EA).

Polypropylene-nanodiamond composite for hernia mesh.

Commercial hernia mesh is commonly made from polypropylene (PP), due to its inertness, biocompatibility, physical properties, ease of processing and versatility for conversion into flexible shape. However, reportedly hernia mesh prepared from PP experienced issues such as diminished long-term strength, foreign body rejection, lack of biocompatibility and high adhesion to the abdomen wall. Infiltration of the mesh by soft tissue (called remodeling) results in an integration of mesh into the body, leading to a rapid reduction in mesh mechanical properties and potential infection. Here, this study addresses these issues through the incorporation of nanodiamond (ND) into PP filament and coating on the surface of plasma-treated PP-ND mesh. The results show that the dynamic modulus of the PP-ND mesh increased significantly, without compromising its flexibility. Coating PP-ND mesh with hydroxylated ND led to a reduction in nonspecific protein adsorption onto the surface of nanocomposite, which is an important characteristic for hernia mesh to prevent foreign body reaction, attachment of mesh to the abdominal wall and nearby organs. In-vitro study with mammalian cells shows that coated PP-ND mesh with functionalized ND exhibits a significant increase in the number of adhered cells with more elongated morphology in comparison with other PP meshes, due to the better hydrophilicity. Therefore, the ND coated nanocomposite mesh can be a promising candidate for hernia repair in the future; however, more investigation is required.

Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature.

BACKGROUND: This study describes our experience of arteriovenous fistula (AVF) creation as vascular access for haemodialysis. MATERIALS AND METHODS: This study has been carried out in our hospital from January 2004 to December 2012. A total of 505 AVFs were created in 443 patients. Maximum follow-up was 8 years, and minimum was 6 months. OBSERVATIONS AND RESULTS: In this study of 505 cases of AVFs, primary patency rates by Kaplan - Meier analysis showed 78.81% patency of fistulas at the end of 1 year and patency dropped to 14.81% at the end of 5 years. Our primary failure rate was 21.2%. Basilic vein was used in 26.35% cases, cephalic vein in 63.5%, and antecubital vein in 9.75% cases. On table, bruit was present in 459 (90.9%) and thrill in 451 (89.3%) cases. During dialysis, flow rate >250 ml/min was obtained in 150 (29.9%) cases. In complications, 2 (0.4%) patients developed distal oedema, 33 (6.5%) developed steal phenomenon. CONCLUSIONS: Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is <2 mm, chances of AVF failure are high. Flow rates in patients with vein diam. >2 mm were significantly higher as compared with patients with vein diam. <2 mm (P < 0.001). Flow rates are higher in non-diabetic patients as compared to diabetic patients (P < 0.001). Average blood urea and serum creatinine values are significantly lesser in patients undergoing dialysis through successful fistulas as compared to patients with failed fistulas. Correspondingly, incidence of deaths is significantly lesser in patients with successful fistulas. During proximal side-to-side fistula between antecubital/basilic vein and brachial artery, dilating of the first valve toward wrist helps to develop distal veins in the forearm by retrograde flow. This technique avoids requirement of superficialization of basilic vein in the arm.