Diagnosis and management of selective fetal growth restriction in monochorionic twin pregnancies: A cross-sectional international survey.

OBJECTIVE: To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies. DESIGN: Cross-sectional survey. SETTING: International. POPULATION: Clinicians involved in the management of MCDA twin pregnancies with sFGR. METHODS: A structured, self-administered survey. MAIN OUTCOME MEASURES: Clinical practices and attitudes to diagnostic criteria and management strategies. RESULTS: Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide. CONCLUSIONS: There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Pitfalls and management of corrective spinal surgery in trisomy 9 mosaicism: a report of three cases.

PURPOSE: The aim of this case series is to present the outcomes of surgical correction of hyperkyphosis, and subsequent management of complications for three patients with a rare chromosomopathy, Trisomy 9 Mosaicism (T9M). METHODS: Case series with 2 year outcomes following index surgery. RESULTS: Case 1 presented at 9 years of age with 103° of kyphosis (T3-T10), which progressed to 118° despite bracing. Case 2 presented at 7 years of age with 113° of kyphosis (T3-T11). Case 3 presented at 4 years of age with 103° of kyphosis (T1-T11). Cases 1 and 2 underwent T2-L2 posterior instrumented spinal fusion (PISF). Upon follow up, radiographs for Cases 1 and 2 revealed severe, symptomatic proximal junctional kyphosis (PJK) of 71° and 50°, respectively, requiring surgical revision proximally to the C4 level. Case 3 underwent placement of magnetically controlled growing rods given young age and growth potential. Surgical levels for Case 3 were extended from C4-pelvis in an attempt to prevent development of symptomatic PJK. Most recent radiographs for Case 3 taken 21 months postoperatively demonstrate a stable 50° of kyphosis. PJK above C4 was noted but is stable and asymptomatic. CONCLUSION: T9M often presents with progressive hyperkyphosis. Despite instrumentation above the upper end vertebra (UEV), PJK may be a common complication in this small patient population. This novel report on spine deformity correction in the T9M population may provide preliminary guidance for the treatment of hyperkyphosis in patients with T9M and help surgeons avoid common pitfalls. LEVEL OF EVIDENCE: IV.