Persistent omphalomesenteric duct in an infant with trisomy 21.

We present the case of a term newborn with trisomy 21 who presented to the paediatric emergency department with periumbilical flare and green-brown discharge from a clamped umbilical cord, initially suspected to be omphalitis. However, it was noticed later, that when the infant strained or cried, a thick, bubbling and offensive green-brown discharge came out of the clamped umbilical cord with umbilical flatus. An ultrasound abdomen and umbilical cord confirmed the presence of a persistent omphalomesenteric duct (POMD). He was then transferred to the paediatric surgical unit. There, he underwent a laparotomy and surgical resection of the POMD and was discharged home 2 days later.

Surgery and paediatric inflammatory bowel disease.

The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.

Perioperative Complications of Surgery for Hypertrophic Pyloric Stenosis.

Pyloromyotomy is the tried and tested surgical procedure for successful operative treatment of pyloric stenosis. Over time, the operative approach has evolved to take advantage of cosmetically superior incisions and more recently minimally invasive surgery. During and following surgery, complications are uncommon. The specific complications of an inadequate pyloromyotomy requiring repeated procedure and mucosal perforation during an overzealous pyloromyotomy represent the ends of a spectrum within which sits the perfect procedure. Here, we discuss these specific complications together with the other potential complications following surgery for hypertrophic pyloric stenosis, including anesthetic considerations.

Long-term outlook in biliary atresia.

The oldest survivors from the Kasai portoenterostomy originate in Sendai, Japan and are approaching their 60th birthday. These represent the tip of an expanding cohort of adults born with this previously fatal condition. Increasingly transition to adult-biased hepatologists and physicians will be the expectation of many with this condition. However unlike their usual patients with alcohol, drugs, virally mediated liver disease these are different with different expectations of health and quality of life. Cure is not on the cards for most of these and they survive still with impaired bile flow and increased liver fibrosis and cirrhosis with the threat of cholangitis and portal hypertension still apparent. We review the reported statistics on long-term survival essentially from Japan and Western Europe (such as the UK and France) and the range of complications that may still beset this group.

Ten-year single-centre experience with type II endoleaks: Intervention versus observation.

Our objective was to determine the relative merits of intervention or observation of type II endoleaks (T2Ls). A retrospective analysis was performed on 386 infra-renal endovascular aneurysm repair (IR-EVAR) patients from 2006 to 2015. Annual surveillance imaging of patients undergoing EVAR at our centre were analysed, and all endoleaks were subjected to a multidisciplinary team meeting for consideration and treatment. In the 10-year time frame, 386 patients (79.5±8.7 years) underwent an IR-EVAR. Eighty-one patients (21.0%) developed a T2L and intervention was undertaken in 28 (34.6%): 17 (60.7%) were treated via a transarterial approach (TA) and 11 (39.3%) using the translumbar approach (TL). Fifty-three patients (65.4%) with T2Ls were managed conservatively. Patients who received T2L treatment had a greater proportion of recurrent T2Ls than patients who were conservatively managed ( p=0.032). T2Ls associated with aneurysmal growth were more resistant to treatment than those where there was no change or a decrease in aneurysm size during follow-up (0.033). There was no significant difference in the TA and TL approach with respect to endoleak repair success ( p=0.525). Treatment of a T2L did not confer a survival advantage compared to conservative management ( p=0.449) nor did the choice of either the TA or TL approach ( p=0.148). Our study suggests the development of a T2L associated with aneurysm growth may represent an aggressive phenotype that is resistant to treatment. However, this did not lead to an increased risk of mortality over follow-up. Neither a transarterial nor a translumbar approach to treating a T2L conferred superiority.

Open surgery for chronic dissection.

Chronic aortic dissection is one of the most challenging pathologies faced by aortic surgeons. The variety of presentations and the multiple comorbidities of the patients make treatment and follow-up a subject of much debate. Historical data is difficult to interpret because of the heterogeneity of the included populations, and the common tendency of authors to pool outcomes of thoracoabdominal aortic aneurysm repair secondary to degenerative pathology or connective tissue disorder with those who have an underlying dissection. As the endovascular treatment of chronic aortic dissection becomes more commonplace with the increasing use of branched and fenestrated technology, it will be important to have an historical "gold standard" to use as a comparator. This narrative review of the literature describes the challenges to interpretation of data and the available information published about chronic aortic dissection.

Retrograde Stenting Under Transmesenteric Angiographic Guidance of an Occluded Superior Mesenteric Vein to Treat Life-Threatening Hemorrhage.

Midgut carcinoid tumors (MCTs) are responsible for a range of mesenteric vascular complications and may rarely manifest with gastrointestinal (GI) hemorrhage. Endovascular approaches are particularly useful for this population, as surgery is often technically difficult. We report a case of life-threatening upper GI bleeding in a 50-year-old man previously diagnosed with an MCT in the small bowel mesentery. Computed tomography angiogram revealed an MCT obstructing the superior mesenteric vein (SMV) associated with multiple large collateral vessels. The patient underwent retrograde stenting of the obstructed SMV using a combined open and endovascular approach to successfully terminate the persistent GI bleeding.

A rare and potentially fatal cause of popliteal fossa swelling.

Popliteal vein aneurysms (PVAs) represent a rare form of venous aneurysm and necessitate prompt diagnosis and management due to their well-established role as a source of pulmonary emboli. Surgical repair is usually curative; we present the case of a 47-year-old woman with a recurrent PVA presenting as a soft popliteal fossa mass with associated sensory deficit affecting the right foot, 4 years after initial operative repair. Venous duplex imaging demonstrated a saccular aneurysm originating from the posterior wall of the right popliteal vein. In light of the long-term risk of potentially life-threatening pulmonary embolism, surgical repair was undertaken by tangential aneurysmectomy and long saphenous vein patch venoplasty. This case emphasises the importance of including PVA in the differential diagnosis of popliteal fossa swellings as well as the need for long-term follow-up to detect late recurrence with subsequent avoidance of the otherwise significant potential morbidity and mortality.