Colon patch esophagoplasty for esophageal strictures refractory to multi-modal treatment revisited.

INTRODUCTION/PURPOSE: Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports. MATERIALS AND METHODS: A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed. RESULTS: Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6 year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8 years and had 17 to more than 25 dilations following caustic ingestion over a 2-5 year period. One patient had a 4 cm stricture; the other 2 had strictures 7 cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36 month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5 months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach. CONCLUSION: Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications.

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

Uneventful survival of a rural child after penetrating cardiac injury by a thorn: a case report.

BACKGROUND: Paediatric penetrating cardiac injury is extremely rare, precluding published management guidelines, therefore warranting a case-by-case approach with learning points gleaned from each case. CASE SUMMARY: A 7-year-old boy presented to a rural hospital with a stab wound to the chest by a Withaak (Vachellia tortilis) thorn. The patient was haemodynamically stable on presentation, but a 2 cm subcutaneous, pulsatile mass was present at the cardiac apex. Echocardiography revealed a foreign body penetrating from the apex into the heart, with evidence for a fistula between a cardiac chamber and the pulsatile mass. Angiography confirmed the existence of the fistula between the right ventricle (RV) and the pulsatile mass. A controlled extraction under general anaesthaesia via median sternotomy was performed in-theatre, with blood products and cardiac bypass on standby. The patient recovered without complications and was discharged after 4 days. DISCUSSION: Our case illustrates the limitations of echocardiography in identifying the precise anatomical definition of penetrating cardiac injuries. Angiography is therefore indicated in such cases. The injury to the RV and the haemostatic effects of the in situ thorn were favourable prognostic factors. We believe that the mortality risk reduction of extraction under full control warrants the minor morbidity of a median sternotomy.

A simple scoring system to train surgeons in basic laparoscopic skills.

AIM: To develop and validate a scoring system for a training assessment tool using a box trainer which can objectively demonstrate progression in laparoscopic skills. METHOD: 170 assessments were performed over a 5-year period by doctors working in a busy paediatric surgical department. Each participant was scored based on experience and then undertook six laparoscopic tasks in a box trainer in a dry skills lab. The quicker and more accurate the performance, the lower the score. Validity and reliability tests were applied. RESULTS: Pearson correlation coefficient demonstrated that more experienced surgeons performed better than novices with an r of -0.63 (p < 0.001). The mean assessment scores improved (reduced) with increasing experience score [4140 (0-20), 2696 (21-40), 1969 (>40) p < 0.001]. Improvement in score was seen at all experience levels with greatest improvement seen in the less experienced (2315, 1820, 1571 p < 0.001). Cronbach's alpha was 0.70 and the intraclass correlation coefficient for test-retest reliability was 0.81. CONCLUSION: Construct validity with adequate reliability has been demonstrated for this simple training tool and scoring system. All experience levels demonstrated improvement in their laparoscopic skills by simulation training in a laparoscopic box trainer.

First insights into species and genotypes of Echinococcus in South Africa.

Cystic echinococcosis is a serious and neglected parasitic zoonosis that is regarded as an emerging disease world-wide. Effective control of the disease is based on understanding the variability of Echinococcus granulosus (sensu lato), as genotypic characteristics may influence lifecycle patterns, development rate, and transmission. No molecular epidemiological research has previously been conducted to shed light on genotypes responsible for the disease in South Africa. To identify strains circulating in the country, parasite material was collected from patients between August 2010 and September 2012 and analyzed by PCR/RFLP methods. A total of 32 samples was characterized as E. granulosus sensu stricto (G1-G3) (81%), E. canadensis (G6/7) (16%) and E. ortleppi (G5) (3%). Furthermore, two co-amplifying G6/7 genotypes were confirmed as G7 by sequencing. This is the first report on genotyping of Echinococcus species in South Africa, and, to the best of our knowledge, the first report of the G5 and G7 genotypes from humans in Africa.

Inhibition of neointimal formation and hyperplasia in vein grafts by external stent/sheath.

Synthetic and to a lesser extent vein graft failure is still a major problem in the treatment of peripheral arterial disease, with neointimal hyperplasia being the main cause for graft occlusion in the medium and long term. This review aims to establish the current status of external stents or sheaths in the prevention of intimal hyperplasia in small diameter (< 6 mm) vein grafts.