Hospital revisits after paediatric tonsillectomy: a cohort study

Background Tonsillectomy, with or without adenoidectomy, is the leading reason for paediatric unplanned hospital readmission, some of which are potentially avoidable. Reducing unplanned hospital revisits would improve patient safety and decrease use of healthcare resources. This study aimed to describe the incidence, timing and risk factors for any surgery-related hospital revisits (both emergency presentation and readmission) following paediatric tonsillectomy and adenotonsillectomy in a large state-wide cohort. Methods We conducted a population-based cohort study using linked administrative datasets capturing all paediatric tonsillectomy and adenotonsillectomy surgeries performed between 2010 and 2015 in the state of Victoria, Australia. The primary outcome was presentation to the emergency department or hospital readmission within 30-day post-surgery. Results Between 2010 and 2015, 46,583 patients underwent 47,054 surgeries. There was a total of 4758 emergency department presentations (10.11% total surgeries) and 2750 readmissions (5.84% total surgeries). Haemorrhage was the most common reason for both revisit types, associated with 33.02% of ED presentations (3.34% total surgeries) and 67.93% of readmissions (3.97% total surgeries). Day 5 post-surgery was the median revisit time for both ED presentations (IQR 3–7) and readmission (IQR 3–8). Predictors of revisit included older age, public and metropolitan hospitals and peri-operative complications during surgery. Conclusions Haemorrhage was the most common reason for both emergency department presentation and hospital readmission. The higher risk of revisits associated with older children, surgeries performed in public and metropolitan hospitals, and in patients experiencing peri-operative complications, suggest the need for improved education of postoperative care for caregivers, and avoidance of inappropriate early discharge. Graphical Abstract

Foregut Issues After Bariatric Surgery

Weight loss surgery has overall been shown to be very safe and effective. However, long-term outcomes data has allowed codification of post-operative complications specific to the type of weight loss surgery performed. This review focuses specifically on foregut-related postoperative complications after weight loss surgery, most of which are not discussed on a broad scale in the literature yet whose prevalence continues to rise. Clinicians should maintain a broad differential when treating patients with complications after bariatric surgery in order to perform a thorough and precise workup to identify the diagnosis and guide management.

Cochlear Implantation in Advanced Otosclerosis: Pitfalls and Successes

Purpose of Review This review will highlight recent outcome-based evidence guiding decision making for cochlear implantation in advanced otosclerosis, related complications, and technical surgical considerations in otosclerosis and the obstructed cochlea. Recent Findings Cochlear implantation in advanced otosclerosis results in consistent, excellent auditory outcomes with improvement in both objective speech recognition scores and subjective quality of life measures. Facial nerve stimulation may occur at higher rates in otosclerosis cochlear implant recipients. Cochlear implantation in the setting of luminal obstruction in osteosclerotic patients may be managed with altered surgical technique to achieve successful auditory improvements. Pre-operative imaging with high resolution CT or MRI may help anticipate intraoperative challenges and post-operative complications in cochlear implantation. Summary Cochlear implantation is an established, successful treatment for profound hearing loss in advanced otosclerosis. Surgeon knowledge of outcomes, complications, and potential surgical challenges is important to appropriately counsel patients regarding auditory rehabilitation options in advanced otosclerosis.

Hybrid extracorporeal membrane oxygenation (ECMO) cannulation following traumatic pneumonectomy: A case report

A 28-year-old man presented in extremis after a motorcycle crash. Following traumatic pneumonectomy, he developed right heart failure and was placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) only to transition to veno-arteriovenous (VAV) ECMO due to persistent hypoxemia. Resulting flow limitation caused distal ischemia of his left leg, requiring thrombectomy and fasciotomy. Potential loss of limb necessitated transitioning to veno-venous (VV) ECMO from which he was successfully decannulated thereafter. ECMO can bridge recovery following the most dire injuries, and hybrid strategies can ameliorate post-operative complications; however, ECMO itself carries significant risks that must be weighed against intended benefit.

Post-operative Complications of Complicated Paediatric Appendicitis in a Tertiary Teaching Hospital

Background: Acute appendicitis is a common surgical problem, with complicated appendicitis having significant post operative complications, which contribute significantly to cost of medical care. Methodology: A hospital based retrospective study was conducted in department of paediatric surgery, Thiruvananthapuram. Study population consisted of children treated with complicated appendicitis from January 2016 to June 2021. Results: The study had 30.4% surgical site soft tissue infection (SSI). There was 13.48% incidence of major complication, with laparoscopic and open appendicectomies having similar incidence even though not statistically significant. SSI was more common with appendicular abscess and post ileal appendix. Post operative intra-abdominal abscess is more common with open appendicectomy, generalised peritonitis, post ileal appendix and base/proximal perforation of appendix. Post operative adhesive intestinal obstruction was more common with laparoscopic appendicectomy, appendicular abscess and base/proximal perforation of appendix. Total hospital stay correlates significantly with duration of symptoms on presentation with mean hospital stay of 7.72 days. Conclusion: Complicated appendicitis have high incidence of post operative complications, 30.4% SSI and 13.48% serious complications like intra-abdominal collection and adhesive intestinal obstruction. Keywords: Appendicitis, Complication, Surgical site infection, Children.

Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management

Traumatic duodenal injuries are rare and often challenging to diagnose and treat. Management of these injuries remains controversial and continues to evolve. Here, we performed a review of the literature and guidelines for the diagnosis and management of traumatic duodenal injuries. A common recommendation in more recent literature is primary, tension-free repair of duodenal injuries when possible if surgical repair is necessary. Conversely, if duodenal injuries are unamenable to primary repair, more complex procedures such as Roux-en-Y duodenojejunostomy or pancreaticoduodenectomy may be necessary. Regardless of injury grade or type of surgical repair, the literature continues to support wide extraluminal drainage. Over time, the management of complex duodenal injuries has evolved to favor simple primary repair whenever possible. According to recent studies, more complex procedures are associated with higher rates of post-operative complications and should be reserved for severe injuries when primary repair is not possible.

Non-descent vaginal hysterectomy surgery associated with less complications and good prognosis

Background: Removal of the uterus through vagina when performed in a case without uterine descent or prolapse is known as “non-descent vaginal hysterectomy” or NDVH. Vaginal route is preferred as compared to laparoscopic and abdominal methods. The advantages of vaginal hysterectomy being fewer complications, less post-operative stay, cost effective, and useful in bulky uterus. Aims and Objectives: The aims of the study were as follows: (1) To study the intraoperative and post-operative complications encountered during NDVH and their management. (2) To assess the intraoperative blood loss, the operative time, and post-operative hospital stay. (3) To study and check the feasibility of vaginal route as the primary route for all hysterectomies in the absence of uterine prolapse. Materials and Methods: A total of 50 patients were included in the study. Detailed history was taken including obstetric history and menstrual history and clinical examination was performed. After taking written, informed consent and doing proper pre-operative preparation, the patient was posted for NDVH. Post-operative complications were noted. Patients were asked to come for follow-up after 15 days. Results: In 92% of cases operated, no intraoperative complications were found suggesting low morbidity associated with the procedure. Hemorrhage requiring blood transfusion was found in 4% of cases. Average operative time was 61.2 ± 27.89 min, average blood loss was 170 ± 81.44 ml, and average hospital stay was 5.94 ± 4.95 days. On histopathological examination, 40% were having leiomyoma and dysfunctional uterine bleeding was seen in 22% of cases. Pain was the most common complication seen in 30% of cases while vaginal discharge was seen in just 4% of cases. About 80% of patients were discharged on post-operative day 5. Conclusion: In 92% of NDVH cases, no intraoperative complications were found suggesting low morbidity associated with the procedure. The post-operative hospital stay was restricted to 5 days in 80% of cases which indicates early discharge of the patient. Post-operative complications such as vaginal discharge and fever were seen only in 4% of cases. NDVH should, therefore, be considered as the primary route for all hysterectomies unless contraindicated in the absence of prolapse.

Indications and Outcomes of the Kocher-Langenbeck Surgical Approach in the Management of Acetabular Fractures in a Resource Limited Setting

The Kocher-Langenbeck (K-L) approach is the ‘workhorse’ of surgery for acetabular fractures needing posterior fixation. It is indicated for most of these fractures for proper surgical technique and optimal outcome. We therefore evaluated the outcome of surgically treated acetabular fractures through the K-L approach in our setting with limited resources. 57 patients were operated by the K-L approach during the 3-year study period. The most common indications of this approach were: posterior wall (38.6%) and transverse + posterior wall fractures (36.8%). Based on Matta’s criteria of fracture reduction, 81 % were judged anatomic, 16% imperfect and 3 % poor. A surgery waiting time of 8 to 14 days after injury, significantly favoured anatomic fracture reduction. The MAP score was excellent in 72 % and unacceptable in 10.6 %. Factors associated with poor outcomes were poor fracture reduction and the development of early post-operative complications. Iatrogenic sciatic nerve palsy (ISNP) was the most significant post-operative complication (19.3%). The levering of Hohmann retractors in the sciatic notches was the major risk factor for developing ISNP, compared to the use of sciatic nerve retractors. Other early and late complications included surgical site infections (12.3%) and heterotopic ossification (8.8 %), respectively. The overall outcome following surgery by the K-L approach is satisfactory. However, there is need to ameliorate the technique, especially at the level of instrumentation, to limit post-operative complications.

Outcome of laparoscopic cholecystectomy in terms of intraoperative complications in a tertiary care hospital.

Objectives: The main objective was to evaluate the outcome of laparoscopic cholecystectomy in terms of intra-operative complications and the rate and reasons of conversion to open cholecystectomy. Study Design: Descriptive Study. Setting: Hayatabad Medical Complex, Peshawar. Period: June 2018 to May 2019. Material & Methods: After taking consent of Hospital ethical & research committee, patients admitted with clinical diagnosis of cholelithiasis and chronic cholecystitis, confirmed by abdominal ultrasound, undergoing laparoscopic cholecystectomy fulfilling inclusion criteria were selected. Results: A total of 150 were included in the study. Mean age was 39.2yrs with female to male ratio of 9.75:1. Laparoscopic cholecystectomy was successfully accomplished in 98% cases. In 2% (3 patients) converted cases the most common cause of conversion observed was dense adhesions in the calots triangle. Intra-operative complications were noted in 1.4% patients, those included bile duct injury and leakage from the gallbladder bed. However other complications such as bowel injury, blood vessel injury, and post operative hemorrhage did not occur. Overall morbidity was 1.4% with no mortality. Conclusion: Laparoscopic cholecystectomy is a safe and effective procedure in our setup to the accepted standards, as evident by the national and international studies. And it can be accomplished with minimal morbidity and low rate of conversion with the increasing surgeon’s experience.