Risk factors and management of stoma-related obstruction after laparoscopic colorectal surgery with diverting ileostomy

BackgroundStoma-related obstruction (SRO) is defined as small bowel obstruction occurring around the limbs of diverting ileostomy (DI). This study was aimed to investigate the incidence, risk factors, and management of SRO after laparoscopic colorectal surgery with DI creation.MethodsThis study included 155 patients who underwent laparoscopic colorectal surgery with DI creation for rectal cancer (n = 138), ulcerative colitis (UC) (n = 14), and familial adenomatous polyposis (FAP) (n = 3) between 2011 and 2019. Univariate and multivariate analyses were performed to identify the risk factors of SRO.ResultsThe incidence of SRO was 7.7% (n = 12), and it was significantly lower (P < 0.01) in patients with lower anterior resection or intersphincteric resection (4.3%) than in those with ileal-pouch anal anastomosis (IPAA) (35.2%). The multivariate analysis revealed that IPAA was independently associated with the development of SRO (P = 0.001; odds ratio, 9.4; 95% confidence interval, 2.5–35.4). Eleven of 12 patients (92%) with SRO required trans-stomal tube decompression, and 8 of those (67%) underwent early stoma closure.ConclusionIPAA was an independent risk factor of SRO in laparoscopic colorectal surgery with DI creation. Early stoma closure was needed in most cases of SRO.     

Relationship between nasal septum morphology and nasal obstruction symptom severity: computed tomography study

IntroductionThe impact of the nasal septum morphology on the severity of obstruction symptoms has not been fully explored.ObjectiveThis study aimed to investigate whether the morphology of the deviated nasal septum assessed by computed tomography may explain nasal obstruction severity.MethodsThe study included 386 patients who were referred to the computed tomography examination of the paranasal sinuses. Patient selection criteria were the absence of facial anomalies, facial trauma, nasal surgery, and sinonasal tumors. Computed tomography images were used to estimate deviated nasal septum prevalence, the prevalence of Mladina's seven types of deviated nasal septum, and to measure the deviated nasal septum angle. Nasal obstruction severity was assessed by the nasal obstruction symptom evaluation, NOSE scale. The relationship between NOSE score, deviated nasal septum morphology, and deviated nasal septum angle was performed by a statistical regression model on the reduced sample of 225 patients.ResultsThe prevalence of deviated nasal septum was 92.7%. Type 7 deviated nasal septum was the most frequent (34.2%) followed by type 5 (26.2%) and type 3 (23.6%). The worst NOSE scores were recorded in the type 2 deviated nasal septum (45.00 ± 28.28). The mean deviated nasal septum angle in patients with nasal obstruction was 8.5° ± 3.24. NOSE scores were not significantly associated with deviated nasal septum types and angles.ConclusionPatients with different types of deviated nasal septum have different NOSE scores. Computed tomography morphology of the deviated nasal septum could not fully explain the severity of nasal obstruction.     

A subjective analysis of participants’ views in a study of experimental modelling of imposed airway obstruction in infants and children

Deliberate airway obstruction is a well-recognised form of child abuse and one of the most common causes of death in cases of child homicide. Although classical signs such as petechial haemorrhages can be helpful in raising the suspicion of mechanical asphyxia, they are not always present. Therefore, distinguishing between bruising caused by accidents, medical conditions or non-accidental injury remains challenging. We aimed to characterise bruising patterns which are potentially more consistent with deliberate airway obstruction by means of an experimental modelling study. The first results of our project were previously published and demonstrated that bruising anywhere on the head may be consistent with deliberate upper airway obstruction. In this paper, we present the findings of a questionnaire carried out during the modelling to assess participants’ perception of force and consider how variables such as age, use of adjuncts and force distribution may affect bruising patterns in deliberate airway obstruction. Statistical analysis of our results showed that participants felt they were using less force in scenarios involving the infant rather than the child resuscitation dummy as well as when using adjuncts, meaning marks are likely to be more subtle. Therefore, in such cases it is important to examine for other signs of asphyxiation (such as petechiae) and consider the possibility that adjuncts might have been used which could make picking up localised injuries more difficult. Our results also showed that participants often felt force was not distributed evenly across the digits, reporting the greatest force through either the thumb in isolation or the thumb plus another digit in up to nearly 50% of cases. This suggests that just one or two bruises may be consistent with deliberate airway obstruction.     

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BackgroundThe purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).MethodsAfter IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.ResultsAmong 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028–3012] and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).ConclusionsIn this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Level of EvidenceDiagnostic Study, Level III.     

Cardiac-type total anomalous pulmonary venous return is not benign

ObjectiveThe objective of this study was to investigate the association between morphological variation and postsurgical pulmonary vein (PV) stenosis (PPVS) in patients with cardiac total anomalous pulmonary venous connection (TAPVC).MethodsThis single-center, retrospective study included 168 pediatric patients who underwent surgical repair of cardiac TAPVC from 2013 to 2019 (connection to the coronary sinus [CS], n = 136; connection directly to the right atrium [RA], n = 32). Three-dimensional computed tomography modeling and geometric analysis were performed to investigate the morphological features; their relevance to the PPVS was examined.ResultsThe connection type had no association with PPVS (CS type: 18% vs right atrial type: 19%; P = .89) but there was a higher incidence of PPVS in patients with a single PV orifice than > 1 orifice (P < .001). Confluence-to-total PV area ratio (hazard ratio, 4.78, 95% CI, 1.86-12.32; P = .001) and length of drainage route (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < .001) had a 4- and 1-fold increase in the risk for PPVS in the CS type after adjustment for age and preoperative pulmonary venous obstruction. In the right atrial type, those with anomalous PV return to the RA roof were more likely to develop PPVS than to the posterior wall of the RA (P < .001).ConclusionsThe number of inter-junction PV orifice correlated with PPVS development in cardiac TAPVC. The confluence-to-total PV ratio, length of drainage route, and anomalous PV return to the RA roof are important predictors for PPVS. Morphological subcategorization in this clinical setting can potentially assist in surgical decision-making.