Samantha Chippington

Fluoroscopic Balloon Dilation of Esophageal Atresia Anastomotic Strictures in Children and Young Adults: Single-Center Study of 103 Consecutive Patients from 1999 to 2011

PURPOSE To determine whether fluoroscopic balloon dilation (FBD) is a safe and effective method of treating esophageal anastomotic stricture after surgical repair in an unselected patient population. MATERIALS AND METHODS With ethics committee approval, records for 103 consecutive patients who underwent FBD with our interventional radiology service (1999-2011) were reviewed retrospectively. Patients underwent diagnostic contrast material-enhanced study prior to the first dilation. Dilations were performed by using general anesthesia. Outcomes were number and/or frequency of dilations, clinical effectiveness and response to dilations, esophageal perforation, requirement for surgery, and mortality. Data were expressed as mean ± standard deviation (with range). Comparisons were conducted by using the Fisher exact test and log-rank test. The significance level was set at P < .05. RESULTS One hundred three patients (61 male patients, 59%) underwent 378 FBD sessions (median, two dilations per patient; range, 1-40 dilations). The median age at first FBD was 2.2 years (range, 0.1-19.5 years). The balloon catheter diameters ranged from 4 to 20 mm. FBD was successful in 93 patients (90%): 44 (47%) after single dilation and 49 (53%) after multiple dilations. There was no difference in the proportion of patients who required one dilation and were younger than 1 year versus those who were 1 year of age and older (P > .99; odds ratio, 1.07 [range, 0.43-2.66]). Ten patients (10%) required further procedures: Three underwent stent placement, three underwent esophageal stricture resection, and four underwent esophageal reconstruction. Four esophageal perforations (1%) developed after FBD. Antireflux surgery was performed in 18 patients (17%). There were no deaths. CONCLUSION FBD for anastomotic strictures after esophageal atresia repair is feasible and acceptably safe and provides relief of symptoms in most patients (90%); however, about half require more than one dilation, and surgery is best predicted if more than 10 dilations are required.

Primary obstructive megaureter: Cutting balloon endo-ureterotomy

OBJECTIVE In this video we will demonstrate endo-ureterotomy using a cutting balloon for vesico-ureteric junction (VUJ) dilatation and stenting of the primary obstructive megaureter. METHOD For the technique, a 0.014 inch guide-wire is endoscopically inserted through the VUJ and allowed to curl in the megaureter. A 3 mm atherotome-bladed cutting balloon is inflated with iohexol contrast solution. Under fluoroscopy or cystoscopically, the stenotic VUJ segment is observed to open and post-dilated with a 4 mm simple balloon before JJ stent placement for six weeks. RESULTS This video demonstrates the equipment and technique of VUJ endo-ureterotomy using a cutting balloon and stenting of the primary obstructive megaureter. CONCLUSION Where intervention for the primary obstructive megaureter is indicated, we propose VUJ endo-ureterotomy as the first line treatment.

Phrenic nerve injury after image-guided insertion of a tunnelled right internal jugular central venous catheter

Central venous catheters (CVC) are now commonly inserted by radiologists. Although complications are infrequent, they must be avoided where possible and recognized when they occur. We present a 10-year-old boy who developed right hemidiaphragmatic paralysis, requiring surgical plication, following US-guided insertion of a tunnelled right internal jugular CVC. The needle trajectory for internal jugular puncture must be planned to avoid the phrenic nerve.

Radiology service at Great Ormond Street Hospital.

224 www.thelancet.com Vol 378 July 16, 2011 pro gressive. Yet The Lancet fails to acknowledge this in its pursuit of a resignation based on innuendo and presumed truths. This Trust has many staff whose views are not represented by the quotes presented in your journal. Indeed, The Lancet admits that the disaff ected are a minority among the consultants. Moreover, consultants represent less than 7% of the GOSH workforce, every member of which is expected to be committed to highquality care for children. We do not dismiss the anxieties of this small minority and indeed there has been a meeting with those who raised the issues, which was described by both sides as “useful”. We have invited every member of staff to raise any concerns they have by either the recognised management structure, directly with us, via a dedicated electronic reporting system, or via an independent nonexecutive director. What is clear is that the vast majority of our staff remains mystifi ed by the allegations made. If The Lancet took the trouble of coming to speak to staff and patients then perhaps a diff erent story would emerge. The Lancet’s Editor appears only to have selective evidence. We invite The Lancet’s editorial team to visit GOSH to hear directly from the full range of staff and to see the way we are transforming health care for children. We aim at continuous improvement, clinical excellence, and the safety of children, in an atmosphere of openness and transparency.

Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes

PurposeRadiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice.MethodsRetrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature.ResultsBoth RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations.ConclusionsThe choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient.