Assessment of jejunal interposition perfusion using indocyanine green.

INTRODUCTION: Jejunal interposition (JI) is an option for oesophageal replacement in children; ensuring good graft perfusion is essential. We report three cases where Indocyanine Green (ICG) with Near-Infrared Fluorescence (NIRF) was used to assess perfusion during graft selection, passage into the chest and anastomotic assessment. This extra assessment may reduce risk of anastomotic leak and/or stricture. METHODS: We describe the technique and salient features of all patients who have undergone ICG/NIRF-assisted JI in our centre. Patient demographics, indications for surgery, intra-operative plan, video of NIR perfusion assessment, complications and outcomes were reviewed. RESULTS: ICG/NIRF was used in three patients (2M:1F) at a dose of 0.2 mg/kg. ICG/NIRF imaging helped select the jejunal graft and confirmed perfusion after division of segmental arteries. Perfusion was assessed before and after passing the graft through the diaphragmatic hiatus and before and after making the oesophago-jejunal anastomosis. Intrathoracic assessment at the end of the procedure confirmed good perfusion of mesentery and intrathoracic bowel. In two patients, the reassurance contributed to successful procedures. In the third patient, graft selection was satisfactory, but borderline perfusion on clinical assessment after passing the graft to the chest, confirmed by ICG/NIRF meant the graft was abandoned. CONCLUSIONS: ICG/NIRF imaging was feasible and augmented our subjective assessment of graft perfusion, giving greater confidence during graft preparation, movement, and anastomosis. In addition, the imaging helped us abandon one graft. This series demonstrates the feasibility and benefit of ICG/NIR use in JI surgery. Further studies are required to optimise ICG use in this setting.

Triple Atresia, Triple Threat? An Unusual Constellation of Primary Surgical Abnormalities.

We present a case series of two patients with tracheo-oesophageal fistula with oesophageal atresia (TOF/OA), duodenal atresia (DA) and ano-rectal malformation (ARM). This constellation of abnormalities, dubbed triple atresia (TA), is a rare combination with few described cases in the literature. Here we describe our management of these cases, as well as the results of our literature review. Both of our cases had staged surgical procedures and were initially managed with thoracotomy for repair of TOF/OA on day two of life. They subsequently underwent laparotomy for management of their abdominal pathology at day five and seven of life. Both have survived the neonatal period and are awaiting definitive surgery for ARM. Literature review yielded seven cases of TA involving a TOF, DA, and ARM. Four patients underwent staged repair, while three patients underwent repair of TOF/OA, DA and colostomy for ARM at the same time. Of these three patients, two died, representing 22% of the overall cohort. Triple atresia remains a rare subset of patients suspected to have VACTERL association, however mortality may be significantly higher. Our data would suggest a staged approach to be optimal for long term survival.

Intravesical gentamicin instillation for the treatment and prevention of urinary tract infections in complex paediatric urology patients: evidence for safety and efficacy.

BACKGROUND: Little has been reported to date on the instillation of antimicrobials directly into the bladder in children. Children with complex urinary tract anomalies struggle frequently with recurrent urinary tract infections (UTI), with frequent emergence of antibiotic resistance. Gentamicin bladder instillation to treat and prevent UTI was described in children since 2006. OBJECTIVE: We adopted gentamicin bladder instillation in 2016 and evaluate herein our intermediate-term experience with it. STUDY DESIGN AND METHODS: This study is a retrospective review of a prospectively initiated database and a clinical audit of our practice. The gentamicin bladder instillation was employed in 24 cases. A treatment regime was initiated for symptomatic documented UTI when resistance patterns precluded an oral alternative (14 cases), avoiding hospitalisation for parenteral antibiotics. A prophylaxis regime (19 cases-including 9 of the 14 who received an initial treatment regime) followed at least one breakthrough UTI while receiving oral prophylactic antibiotics. Two instillation volumes (8 mg gentamicin in 20 mL 0.9% NaCl or 20 mg gentamicin in 50 mL 0.9% NaCl) were used to suit different bladder capacities. The irrigation is given twice a day for 7 days in the treatment regime or once a day, every other day, in the prophylactic regime. Gentamicin serum levels (all cases) and audiology/audiometry testing (17/24 cases) were checked to assess the safety of this method. RESULTS: The median age when either the treatment course or prophylaxis regime was started was 3.8 years. The treatment regime was 86% successful (12/14) to suppress an acute UTI. The mean duration of prophylaxis was 252 days (median: 256 days). The percentage of patients on the prophylactic regime who had no breakthrough UTI was 58%. No serum gentamicin was detectable secondary to the intravesical instillation. No attributable cases of sensorineural hearing loss were detected. Gentamicin resistance emerged in one case (4.16%). DISCUSSION: Intravesical administration was feasible via various routes for a spectrum of complex lower urinary tract abnormalities (see Summary Figure). Concerns regarding systemic absorption, nephrotoxicity or ototoxicity were investigated and safety ensured. Limitations include being a small series of non-identical pathologies, albeit categorically similar and being a single-arm study, however, statistical significance was proven descriptively and analytically. CONCLUSION: In selected cases and with the appropriate specialist support and logistics, intravesical gentamicin instillation is well-tolerated and safe to treat and/or prevent urinary tract infections in pateints with complex bladder conditions and lower urinary tract pathologies.

Total esophagogastric dissociation (TEGD): Lessons from two decades of experience.

BACKGROUND: Total esophagogastric dissociation (TEGD) has been performed in our institution since 1994, predating its published description by Bianchi in 1997. Originally it was considered a rescue procedure when conventional antireflux surgery failed. Recently TEGD has been considered a viable primary option for the treatment of gastroesophageal reflux disease (GERD) in severely neurological impaired (NI) patients. We describe our institution's experience of TEGD in this selected cohort of patients. METHODS: An institutional retrospective review was performed detailing our total experience of open TEGD between 1994 and 2015 in severely neurologically impaired (NI) patients. Demographic, complications, and outcome were analyzed. RESULTS: Sixty-six NI patients underwent TEGD between 1994 and 2015 (39 female). Primary TEGD was performed in forty-nine patients (74.2%), while the remainder were rescue procedures following the failure of previous antireflux surgery. In 98% of cases no recurrence of clinically significant reflux was reported. The mean hospital length of stay was 10.2 days. There were sixteen reported complications in twelve patients representing 18.2% of the cohort. One death was attributable to the procedure (1.5%). Median follow-up was 31.6 months (range, 1.3-137.9 months). CONCLUSION: TEGD appears to be a valid surgical option to treat severe GERD in severely neurologically impaired children, both as a primary procedure and as a rescue procedure following failure of anti-reflux surgery. Further studies comparing TEGD versus laparoscopic fundoplication are desirable to understand which of these procedures can be the most effective in this compromised group of patients. TYPE OF STUDY: Retrospective study Level of evidence: IV.