Foregut duplications in the superior mediastinum: beware of a common wall with the tracheo-bronchial tree.

BACKGROUND: Foregut duplication cysts (FD) with a common muscular wall with the oesophagus are well recognised. Our case series highlights the existence of a common wall between superior mediastinal FD and the tracheo-bronchial tree. MATERIALS AND METHODS: Over the last 15 years, we have thoracoscopically resected 41 FD. Five cases were identified to have a common wall with the tracheo-bronchial tree at operation. The clinical history, radiology, findings at operation and pathology were evaluated to highlight learning points. RESULTS: Five superior mediastinal cysts with a common wall were identified, with two antenatally and three postnatally diagnosed. All three postnatal cases and one antenatal case presented with symptoms of respiratory compromise and stridor. Only one neonate was relatively asymptomatic before resection. CT similarities in all cases were: separation of trachea and oesophagus by the cyst, oesophageal deviation to the right or compression and compression of trachea/bronchus. Thoracoscopically, two cysts were resected without injury to the airway, while three had inadvertent tracheo-bronchial injury. Repair of the tracheal injury was possible in one case thoracoscopically, while two cases required conversions, as adequate oxygenation could not be maintained despite on-table endotracheal tube advancement beyond the injury and thoracoscopic manoeuvres. All cases had excellent outcomes at follow-up (median 25months, range 4-39months) with resolution of symptoms and no recurrences. CONCLUSIONS: Our report highlights the existence of a common wall between the superior mediastinal FD and the tracheo-bronchial tree. Thoracoscopic resections are feasible including repair of inadvertent airway injury, provided adequate oxygenation can be maintained.

Foreskin reconstruction vs circumcision in distal hypospadias.

PURPOSE: The purpose of the study was to determine if there were differences in the complication rates between foreskin reconstruction (FR) and circumcision (CIRC) in distal hypospadias repairs. The primary outcomes were urethrocutaneous fistula (UF) and dehiscence. METHODS: The data of distal hypospadias operated between 2005 and 2013 were retrospectively reviewed. The inclusion criteria were any distal hypospadias repair that required an urethroplasty. The exclusion criteria were follow-up <1 year, redo procedures, chordee greater than 20°, and incomplete data. Univariate and multivariate analysis was performed on the results. RESULTS: 213 patients were included (95 FR and 118 CIRC). The 2 groups were comparable for age at surgery 19.32 months in FR and 14.25 months in CIRC. Mathieu repair was more common in FR (47/95-49.47%) than in CIRC (45/118-38.14%). The total subsequent procedures required were 23 in FR and 57 in CIRC. The incidence of UF was 6.3% (6/95) in FR and 27.1% (32/118) in CIRC (p < 0.001, OR 5.52, 95% CI 2.2-13.9). Complete dehiscence rates were 3.16% (3/95) FR vs 11.02% (13/118) for CIRC (p = 0.037, OR 3.8, 95% CI 1.05-13.74). The incidence of patients requiring reoperation was 18.9% (18/95) in FR versus 45.8% (54/118) in CIRC (p < 0.001, OR 3.61, 95% CI 1.93-6.76). CONCLUSIONS: Foreskin Reconstruction conferred a significantly lower rate of complications, particularly the UF rate, dehiscence rate, and number of patients that required reoperation. Our rate of complications in the CIRC group is much higher than other published data.

Surgical education and training in an outer metropolitan hospital: a qualitative study of surgical trainers and trainees.

The landscape of surgical training is changing. The anticipated increase in the numbers of surgical trainees and the shift to competency-based surgical training places pressures on an already stretched health service. With these pressures in mind, we explored trainers' and trainees' experiences of surgical training in a less traditional rotation, an outer metropolitan hospital. We considered practice-based learning theories to make meaning of surgical training in this setting, in particular Actor-network theory. We adopted a qualitative approach and purposively sampled surgical trainers and trainees to participate in individual interviews and focus groups respectively. Transcripts were made and thematically analysed. Institutional human research ethics approval was obtained. Four surgical trainers and fourteen trainees participated. Almost without exception, participants' report training needs to be well met. Emergent inter-related themes were: learning as social activity; learning and programmatic factors; learning and physical infrastructure; and, learning and organizational structure. This outer metropolitan hospital is suited to the provision of surgical training with the current rotational system for trainees. The setting offers experiences that enable consolidation of learning providing a rich and varied overall surgical training program. Although relational elements of learning were paramount they occurred within a complex environment. Actor-network theory was used to give meaning to emergent themes acknowledging that actors (both people and objects) and their interactions combine to influence training quality, shifting the focus of responsibility for learning away from individuals to the complex interactions in which they work and learn.