Early short segment left colon interposition for esophageal atresia

Colon Interposition is frequently used for correction of esophageal atresia. The use of both retrosternal right colon^1–5 and transthoracic left or transverse colon^2,6–10 has been recommended. Retrosternal right colon interposition may be complicated by break downs and/or stricture of the anastomosis between cervical pharyngo-esophagus and the proximal interposed colon;^3–5,9 by vascular compromise and ischemia of the colon segment;^2,5 and by peptic ulceration of the distal interposed colon where it is anastomosed to the stomach.¹¹ Long-segment transthoracic left colon interposition may be attended by the first two complications as well;¹⁰ utilization of the esophageal stump for the distal colo-esophageal anastomosis in this technique may prevent gastroesophgeal reflux.^8–10,12Because of these problems, other methods of treatment have been suggested. The use of a gastric tube as esophageal replacement has been recommended;^13–15 however, peptic ulceration of the gastric esophagus may result.¹⁶ Elongation of the upper and, sometimes, the lower esophageal pouch with delayed primary anastomosis has been advocated.^17–19 Anastomotic leaks and/or stricture frequently accompany this procedure.Short-segment transthoracic left colon interpositions for esophageal stricture or varices have been attended by relatively fewer complications.^6–8 Therefore, a modified procedure was adopted for wide-gap esophageal atresia in 1968. A short segment of left colon was interposed transthoracically between the distal esophageal stump and proximal esophageal pouch in two infants after several weeks of bougienage had stretched the proximal pouch well below the aortic arch, so that a colo-esophageal anastomosis could be accomplished within the thorax without difficulty.     

Tracheoesophageal fistula after lye ingestion

Fistulous communications between the esophagus and tracheobronchial tree as a consequence of lye ingestion are very rare and may occur as a direct result of the caustic, or later, after dilatation of a resulting stricture.¹The experimental production and evolution of caustic burns of the esophagus have been well described.^2,3 The depth of the injury correlates with the concentration of lye both experimentally,⁴ and clinically.⁵ The virtually instantaneous, devastating, and fatal effects of concentrated lye have been emphasized recently.³The following report is that of a child who developed a tracheoesophageal fistula secondary to caustic ingestion which resulted in his death. The patient is presented to indicate the severity of the injury and the radiographic and operative findings.     

Life-threatening anoxic spells caused by tracheal compression after repair of esophageal atresia: Correction by surgery

Three infants who developed anoxic spells 2, 5, and 20 mo following repair of esophageal atresia developed apneic spells during or within a few minutes of feeding. These episodes began with stridor and cyanosis; when severe, they progressed to apnea and loss of consciousness. Mouth-to-mouth resuscitation was often necessary. Investigations failed to detect esophageal obstruction and/or a recurrent tracheoesophageal fistula. No neurologic or cardiac abnormalities were found. The cause was compression of a 1- to 3-cm segment of trachea anteriorly by a vascular structure and posteriorly by a dilated esophagus that emptied slowly because of poor motility. Endoscopy confirmed the x-ray findings. The aortic arch and innominate artery were suspended to the sternum anteriorly, which relieved the apneic spells in all patients.     

Fracture due to shock from domestic electricity supply

This report describes a fracture-dislocation of the shoulder joint due to electric shock. This is the first case reported in an English language journal of fracture due to shock from the domestic electricity supply. Other cases have been reported but not caused by such a low voltage current.     

Intussusception in the older child- suspect lymphosarcoma.

Examination of the records of 378 children with intussusception at our institution revealed that 29 cases were caused by an identifiable intestinal lesion. A Meckel's diverticulum was the causative agent in 21 children, all of whom were under 2 yr of age. A previously undiagnosed ileal lymphosarcoma produced the intussusception in six other children, all between 6 1/2 and 9 yr of age. Our experience indicates that any child over 6 yr of age with the clinical findings of colicky abdominal pain, bloody stools, and a palpable mass plus the radiographic evidence of intussusception must be considered to have ileal lymphosarcoma until proven otherwise. Hydrostatic reduction of the intussusception must be accompanied by extensive small bowel reflux of barium in order to effectively rule out a small intestinal lesion. If this is not accomplished, surgery should be planned with the suspicion that a malignancy may be present. If this suspicion is confirmed by frozen section, the operation procedure should include wide surgical excision of the lesion along with the regional lymph nodes.     

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BackgroundPerioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.ObjectivesTo enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.SettingBariatric surgery centers, United States.MethodsPatients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.ResultsWe identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4–21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2–11.4), hyperlipidemia (OR = 2.60, CI = 1.3–5.1), and age >50 (OR = 2.15, CI = 1.1–4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.ConclusionThe prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.     

Vertebral anomalies associated with esophageal atresia and tracheoesophageal fistula with reference to the initial operative mortality

In a series of 40 patients with esophageal atresia and tracheoesophageal fistula, the incidence of musculoskeletal anomalies was 45% (18 patients). An extra mesodermal segment was found in 15 patients (13 paired thoracic vertebrae and 13 paired ribs in nine patients; six lumbar vertebrae in 6 patients). The mortality in grade A infants with an extra mesodermal segment was significantly higher than in those infants with a normal spine (p > 0.01). It is suggested that segmentation or abnormal segmentation of the embryo may be important as a cause of esophageal atresia.     

Research Pearls: Expert Consensus Based Evidence Using the Delphi Method

The evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable. In principle, there are 2 consensus methods for expert opinion available: the nominal group technique and the Delphi method. The nominal group technique is a structured face-to-face meeting facilitating discussion and allows participants to voice their opinions. The key characteristics of the Delphi method are the use of panel experts to obtain data, no face-to-face discussions, the use of sequential questionnaires, the systematic emergence of a concurrent opinion, use of frequency distributions to identify patterns, and the use of at least 2 rounds with feedback between rounds. We should not dismiss the collective experience of our leading experts, and expert consensus-based evidence should be explored as another tool to improve the quality of treatment for our patients.     

A complication of intramedullary nailing

A case is described of intramedullary nailing of the femur, complicated by non-union, fracture of the nail, pseudarthrosis, malunion and subsequent distal migration of the proximal nail fragment over a period of 8 years.     

Systematic review and meta-analysis of Roux-en-Y gastric bypass against laparoscopic sleeve gastrectomy for amelioration of NAFLD using four criteria

Nonalcoholic fatty liver disease (NAFLD) prevalence is rising worldwide, as a direct consequence of the obesity epidemic. Bariatric surgery provides proven NAFLD amelioration, although questions remain regarding whether Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG) is more effective. To answer this question, we conducted a systematic review and meta-analysis exclusively comparing RYGB and LSG for amelioration of NAFLD using 4 separate criteria: alanine transaminase, aspartate transaminase, NAFLD activity score, and NAFLD fibrosis score. Our search included 1290 initial studies, which were narrowed to 20 final studies in the meta-analysis. Overall, both RYGB and LSG significantly improved alanine transaminase, aspartate transaminase, NAFLD activity score, and NAFLD fibrosis score postoperatively. Direct comparisons of RYGB to LSG in any of the 4 criteria failed to demonstrate superiority. Our findings corroborate the current literature showing that bariatric surgery significantly improves biochemical and histologic parameters in patients with NAFLD. The novel individual comparisons of 4 criteria failed to show superiority between RYGB and LSG in ameliorating NAFLD. Despite several limitations, our study can assist clinicians by supporting the notion that RYGB and LSG may be equally efficacious in ameliorating NAFLD.     

Intramedullary nailing for fractures of the femoral shaft

The results of a survey of 136 fractured femoral shafts treated by open reduction and intramedullary nailing between 1963 and 1970 are presented.Complications of the operation such as mechanical failure of fixation, wound infection, delayed union and non-union are discussed.The final results based on the range of knee flexion and freedom from complications are given: 80 per cent of the results were good.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Duodenal switch: Fully stapled technique

BackgroundDuodenal switch and single anastomosis modifications continue to gain greater interest among bariatric surgeons. Limiting factors to adoption include concerns around the nutritional management, patient compliance and follow-up, and the technical challenge of the operation. The majority of techniques offered currently use a hand-sewn duodenoileostomy. This approach is limited by the steep learning curve as well as longer operating times.ObjectivesWe present a video demonstrating the fully stapled technique for duodenoileostomy and ileileostomy. We offer technical pearls around the technique, specifically focused on maintaining a widely patent anastomosis, open biliopancreatic limb, safe duodenal dissection, and correct loop orientation.MethodsLaparoscopic fully stapled duodenoileostomy for duodenal switch and single anastomosis modification.SettingCommunity hospital, single institution, 3 surgeons.ConclusionTriple staple offers a reproducible and safe technique for the duodenoileostomy and specifically for construction of a Roux or loop anastomosis in duodenal switch.     

Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials

BackgroundBariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications.ObjectivesThis study aims to compare the safety and efficacy of banded versus nonbanded RYGB.SettingMeta-analysis of randomized controlled trials (RCTs).MethodsA meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications.ResultsThree RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m². Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26–8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27–6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups.ConclusionFindings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different.     

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.     

The occult neuropathic bladder

A condition of occult neuropathic bladder can be defined by clinical and radiologic investigations in which the course of the disease closely simulated that observed in the well-defined congenital neuropathies but in which ordinary neurological signs are lacking. The bethanechol stimulation test has some place in confirming this diagnosis, and bethanechol may be of value in this and other forms of neuropathic bladder.     

The incomplete anterior interosseous nerve syndrome

The anterior interosseous nerve syndrome involves paralysis of the flexor pollicis longus, flexor digitorum profundus of the index and long fingers, and the pronator quadratus. We have encountered 33 cases of an incomplete syndrome in which only the flexor pollicis longus or the flexor digitorum profundus of the index finger is either paretic or paralyzed. This entity must be distinguished from flexor tendon rupture, flexor tendon adherence or adhesion, and stenosing tenosynovitis. The nerve is usually compressed by fibrous bands that most commonly originate from the deep head of the pronator teres and to the brachialis fascia. Less common causes of compression are: fibrous bands from the superficial head of the pronator teres; bands from the superficialis arcade; the nerve running deep to both heads of the pronator; and compression by a double lacertus fibrosus. Patients presenting with paresis should be observed. Most will improve spontaneously without surgery. We recommend exploration and neurolysis of the anterior interosseous nerve in patients who present with complete paralysis of either muscle-tendon unit and who have shown no improvement as determined by physical examination or repeat electromyography after 12 weeks of observation. Recovery after neurolysis is often rapid and complete.     

Dysphagia predicts greater weight regain after Roux-en-Y gastric bypass: a longitudinal case-matched study

BackgroundWeight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.ObjectivesWe hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.SettingSingle tertiary care referral center.MethodsThis was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ² and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.ResultsForty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.ConclusionsDysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.     

Editorial Commentary: Imaging of the Anterolateral Ligament of the Knee: The MR(eye) Sees What the Brain Knows…

Significant focus has recently been placed on the contribution of the anterolateral ligament (ALL) to controlling anterolateral rotatory laxity of the anterior cruciate ligament (ACL) injured knee. Many recent studies have investigated the use of magnetic resonance imaging and ultrasound on determining the degree of ALL injury and whether this is correlated to high-grade rotatory laxity. Unfortunately, most studies lack a reference standard, and as such it is challenging to determine whether it truly is the ALL that is injured or if the capsule-osseous layer and deep iliotibial band are involved. Historic literature has demonstrated the importance of these other structures having been noted to be injured at the time of ACL reconstruction. As such, it is clear that high-grade rotatory laxity does not result from an isolated ACL injury. We therefore must remain open to the idea that it is not just the ALL that may cause this injury pattern, and optimal solutions to address this patholaxity have yet to be fully determined.