Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience.

AIM: To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. MATERIALS AND METHODS: An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. RESULTS: The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. CONCLUSION: The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.

[Operative management of penetrating injuries to the subclavian artery. Technical tutorial]. / Operative Versorgung penetrierender Verletzungen der A. subclavia. Technische Anmerkungen.

Penetrating injury to the subclavian arteries is one of the most taxing arterial injuries a trauma surgeon can encounter. Operative access for repair is difficult, crossing two separate anatomical areas-superior mediastinum and base of the neck. The artery runs well protected behind sternum and clavicle and tears easily if clamped. Physiologically unstable patients must be rushed to theatre in an attempt to control exanguinating haemorrhage and to repair the injury. In the rare circumastance of being confronted with it, it is imperative for the occasional trauma surgeon to have a practical operative concept for dealing with this type of injury. This tutorial describes a practical approach for penetrating subclavian injuries, and it discusses alternative surgical strategies when supraclavicular expanding hematomas deny straightforward access.

Management of pancreatic trauma.

BACKGROUND: Pancreatic injury can pose a formidable challenge to the surgeon, and failure to manage it correctly may have devastating consequences for the patient. Management options for pancreatic trauma are reviewed and technical issues highlighted. METHOD: The English-language literature on pancreatic trauma from 1970 to 2006 was reviewed. RESULTS AND CONCLUSIONS: Most pancreatic injuries are minor and can be treated by external drainage. Injuries involving the body, neck and tail of the pancreas, and with suspicion or direct evidence of pancreatic duct disruption, require distal pancreatectomy. Similar injuries affecting the head of the pancreas are best managed by simple external drainage, even if there is suspected pancreatic duct injury. Pancreaticoduodenectomy should be reserved for extensive injuries to the head of the pancreas, and should be practised as part of damage control. Most complications should initially be treated by a combination of nutrition, percutaneous drainage and endoscopic stenting.