The multi-disciplinary management of complex congenital and acquired tracheo-oesophageal fistulae.

AIM OF THE STUDY: Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years. METHODS: We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary. MAIN RESULTS: 14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations. CONCLUSIONS: MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise.

Tissue-Engineered Tracheal Replacement in a Child: A 4-Year Follow-Up Study.

In 2010, a tissue-engineered trachea was transplanted into a 10-year-old child using a decellularized deceased donor trachea repopulated with the recipient's respiratory epithelium and mesenchymal stromal cells. We report the child's clinical progress, tracheal epithelialization and costs over the 4 years. A chronology of events was derived from clinical notes and costs determined using reference costs per procedure. Serial tracheoscopy images, lung function tests and anti-HLA blood samples were compared. Epithelial morphology and T cell, Ki67 and cleaved caspase 3 activity were examined. Computational fluid dynamic simulations determined flow, velocity and airway pressure drops. After the first year following transplantation, the number of interventions fell and the child is currently clinically well and continues in education. Endoscopy demonstrated a complete mucosal lining at 15 months, despite retention of a stent. Histocytology indicates a differentiated respiratory layer and no abnormal immune activity. Computational fluid dynamic analysis demonstrated increased velocity and pressure drops around a distal tracheal narrowing. Cross-sectional area analysis showed restriction of growth within an area of in-stent stenosis. This report demonstrates the long-term viability of a decellularized tissue-engineered trachea within a child. Further research is needed to develop bioengineered pediatric tracheal replacements with lower morbidity, better biomechanics and lower costs.

Bronchomegaly as a complication of fetal endoscopic tracheal occlusion. A caution and a possible solution.

Fetal medicine is developing rapidly and aims to improve the outcome for fetuses with congenital anomalies. Fetal endoscopic tracheal occlusion (FETO) has been developed for fetuses with congenital diaphragmatic hernia to counterbalance the compression of the lung by the abdominal viscera, preserving the pulmonary maturation. Because the perinatal morbidity and mortality of patients treated with FETO have decreased, new complications are emerging in the older survivors. Tracheomegaly has been reported to be a late complication of FETO, sometimes requiring tracheostomy. We report a case of bronchial dilatation after FETO and suggest an alternative surgical treatment.

Patellar resurfacing versus no resurfacing in Scorpio total knee arthroplasty.

This retrospective study compared the results of patellar resurfacing versus no resurfacing in 121 patients (142 knees) who underwent Scorpio total knee arthroplasty (TKA) between January 2002 and September 2004. Mean follow-up was 33 months in the nonresurfaced group and 18 months in the resurfaced group. The 2 groups were similar in age and gender. The incidence of anterior knee pain was 25% in the nonresurfaced group compared to 7% in the resurfaced group (P = 0.05), and the rate of revision was 10% in the nonresurfaced group compared to zero in the resurfaced group (P = 0.013). Mean Euroquol score was 91 in the nonresurfaced group compared to 95 in the resurfaced group (P = 0.26). Euroquol score, Knee Society score, knee instability, return to preoperative functional level, ability to kneel, use of a walking aid, and presence of limp were not significantly different between the 2 groups. The results of this study suggest a more consistent outcome can be achieved with patellar resurfacing in TKA with the Scorpio prosthesis.

Computed tomography versus bronchography in the diagnosis and management of tracheobronchomalacia in ventilator dependent infants.

AIM: To assess the relative accuracy of dynamic spiral computed tomography (CT) compared with tracheobronchography, in a population of ventilator dependent infants with suspected tracheobroncho-malacia (TBM). SETTING: Paediatric intensive care unit in a tertiary teaching hospital. PATIENTS AND METHODS: Infants referred for investigation and management of ventilator dependence and suspected of having TBM were recruited into the study. Tracheobronchography and CT were performed during the same admission by different investigators who were blinded to the results of the other investigation. The study was approved by the hospital research ethics committee, and signed parental consent was obtained. RESULTS: Sixteen infants were recruited into the study. Fifteen had been born prematurely, and five had cardiovascular malformations. In 10 patients there was good or partial correlation between the two investigations, but in six patients there was poor or no correlation. Bronchography consistently showed more dynamic abnormalities, although CT picked up an unsuspected double aortic arch. Radiation doses were 0.27-2.47 mSv with bronchography and 0.86-10.67 mSv with CT. CONCLUSIONS: Bronchography was a better investigation for diagnosing TBM and in determining opening pressures. Spiral CT is unreliable in the assessment of TBM in ventilator dependent infants. In addition, radiation doses were considerably higher with CT.

Intertrochanteric fractures of the femur: a randomized prospective trial comparing the Pugh nail with the dynamic hip screw.

Over a 14-month period, 100 consecutive cases of intertrochanteric fracture were randomly allocated to be treated by either Pugh nail-plate or Dynamic Hip Screw (DHS) fixation. Although there were 11 cases of malreduction and/or suboptimal positioning of the fixation device in the femoral head, only two of these gave long-term problems. Despite the difference in configuration of the devices and a considerable disparity in price, patient satisfaction and the incidence of untoward radiological features at an average of 6 months after surgery were similar in the two groups. A trifin-ended device would thus appear to be a reliable alternative to the more commonly used hip screw systems for intertrochanteric fracture.

Pes planus after tibial osteotomy.

When 100 patients who had had a high tibial osteotomy for monocompartmental arthritis were reviewed, 15 were found to have evidence of neurological impairment. A severe symptomatic pes planus deformity of the ipsilateral limb had developed in 4 patients within months of surgery. Electromyographic results showed evidence of dysfunction in the territory of the posterior tibial nerve in all 4 patients, and, in 3 there was evidence of deep peroneal nerve damage. All had surgery for varus malalignment.

Propofol for inpatient dental anaesthesia. A comparison of propofol as sole anaesthetic agent with thiopentone and halothane for inpatient dental anaesthesia.

The induction, maintenance and recovery characteristics of propofol anaesthesia were compared with thiopentone induction and halothane maintenance in 51 spontaneously breathing, intubated patients who underwent dental surgery. Induction with thiopentone produced fewer side effects than propofol, notably pain on injection. Control of the depth of anaesthesia was better in patients who breathed halothane than in those who received intermittent bolus doses of propofol. Recovery characteristics of the two groups were similar.

Galeazzi fractures in children.

We have reviewed 41 children under 15 years of age with a fracture of the radius and disruption of the inferior radio-ulnar joint. Despite the fact that the joint injury had not at first been recognised in 41% of cases and a variety of treatments had been used, the final results of conservative management were generally good. The more distal the radial fracture, the greater were the problems encountered.

Ankle fractures in the elderly: nonoperative or operative treatment.

One hundred consecutive patients over the age of 60 years with unstable fractures of the ankle were retrospectively reviewed. Fifty were treated operatively and 50 nonoperatively. The mean follow-up was 7 years (2-16 years). Satisfactory reduction was a prerequisite in both groups. Patient satisfaction with regard to pain, deformity, and stability was significantly better in the operated group. The high proportion of poor final results in the nonoperatively treated group correlated well with malunion and nonunion.

Partial closure and other techniques in pilonidal surgery: an assessment of 157 cases.

The report is a retrospective study of 157 patients with pilonidal disease. The period in hospital, the healing time, and the rates of wound breakdown and sinus recurrence were documented following four different methods of management. After incision and drainage of the pilonidal abscess, later excision was necessary in less than 40 per cent of patients. Elective excision of the granulation tissue and skin, with partial closure of the defect, gave better results than excision and primary suture.

A case of 'malignant' diverticulitis associated with tuberculous colitis.

A case of co-existing diverticulitis and tuberculosis of the left side of the colon is presented, the combination resulting in a clinical course identical to so-called 'malignant' diverticulitis.