Intrauterine balloon tamponade in the management of severe postpartum hemorrhage: A case series from a busy UK district general hospital

Objective: To evaluate the effectiveness of balloon tamponade in the management of postpartum hemorrhage (PPH). Methods: Retrospective review of 58 women who underwent balloon tamponade for severe PPH, during a period of 5 years and 10 months, at Russells Hall Hospital, a busy district general hospital in UK. Clinical success was defined as control of bleeding without need for further intervention. Results: Fifty-eight women (mean age, 30 years;range, 18 - 42) underwent balloon tamponade, of which twenty seven (46.5%) women delivered vaginally and 31 (53.5%) women were delivered by cesarean section. Uterine atony was the main cause of PPH (31 cases). Balloon tamponade was used prophylactically in 11 high risk women in anticipation of potential PPH. Rusch balloon was used in 48 cases and Bakri balloon in 10 cases. Clinical success rate of balloon tamponade was 87.2%. Three patients in this study required hysterectomy. Conclusion: Balloon tamponade is an effective means of controlling severe PPH with success rates of around 87%. There should also be a low threshold for prophylactic use of balloon tamponade in women at high risk of PPH, considering its ease of use, low complication rate and ability to maintain reproductive ability.

Newly developed self-expandable Niti-S MD colonic metal stent for malignant colonic obstruction

BACKGROUND Colonic stents are increasingly used to treat acute malignant colonic obstructions.The Wall Flex and Niti-S D type stents are the commonly used self-expandable metallic stents available in Japan since 2012.Wall Flex stent has a risk of stentrelated perforation because of its axial force,while the Niti-S D type stent has a risk of obstructive colitis because of its weaker radial force.Niti-S MD type stents not only overcome these limitations but also permit delivery through highly flexible-tipped smaller-caliber colonoscopes.AIM To compare the efficacy and safety of the newly developed Niti-S MD type colonic stents.METHODS This single-center retrospective observational study included 110 patients with endoscopic self-expandable metallic stents placed between November 2011 and December 2018:Wall Flex(Group W,n=37),Niti-S D type(Group N,n=53),and Niti-S MD type(Group MD,n=20).The primary outcome was clinical success,defined as a resolution of obstructive colonic symptoms,confirmed by clinical and radiological assessment within 48 h.The secondary outcome was technical success,defined as accurate stent placement with adequate stricture coverage on the first attempt without complications.RESULTS The technical success rate was 100%in Groups W,N,and MD,and the overall clinical success rate was 89.2%(33/37),96.2%(51/53),and 100%(20/20)in Groups W,N,and MD,respectively.Early adverse events included pain(3/37,8.1%),poor expansion(1/37,2.7%),and fever(1/37,2.6%)in Group W and perforation due to obstructive colitis(2/53,3.8%)in Group N(likely due to poor expansion).Late adverse events(after 7 d)included stent-related perforations(4/36,11.1%)and stent occlusion(1/36,2.8%)in Group W and stent occlusion(2/51,3.9%)in Group N.The stent-related perforation rate in Group W was significantly higher than that in Group N(P<0.05).No adverse event was observed in Group MD.CONCLUSION In our early and limited experience,the newly developed Niti-S MD type colonic stent was effective and safe for treating acute malignant colonic obstruction.

Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device

BACKGROUND Benign oesophageal strictures carry a significant level of morbidity,causing burdensome symptoms impacting on quality of life.Post-oesophagectomy anastomotic stricture rates as high as 41%have been reported in the literature.These can require endoscopic dilatation,often multiple times to relieve dysphagia.The aim of the present study was to determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures,and to identify any independent risk factors in their development.AIM To determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures,and to identify any independent risk factors in their development.METHODS We performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesophagectomy performed from 2004-2018 to determine the stricture rate.The database comprised a single-surgeon series of open,two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis.Tumour location,histology,neoadjuvant chemotherapy,stapler size,T-stage and R-status were analysed to see if they could predict stricture formation.Stricture was defined as dysphagia requiring endoscopic dilatation.Patients with anastomotic leaks were excluded on the basis they would develop an anastomotic stricture.RESULTS One hundred and seventy patients were collected in the database.Nineteen were excluded on the basis of anastomotic leak,perioperative death and early recurrence.One hundred and fifty-four patients(119 males,35 females)with a mean age of 64±10 years were eligible for analysis.A total of 15 patients developed strictures a median of 99 d(interquartile range:84-133)after surgery,giving a Kaplan-Meier estimated stricture rate of 10%at one year.None of the factors considered were found to be significantly associated with strictures.CONCLUSION In this study the stricture rate was 10%,with the majority occurring in the first 100 d after surgery.No significant independent factors were found in the development of strictures.

A Case of Fungal Keratitis Secondary to Cylindrocarpon Destructans

Purpose: To report the first human case of fungal keratitis caused by Cylindrocarpon destructans and to highlight the issues with the use of topical steroids, the duration of antifungal treatment and the potential role of topical ciclosporin. Methods: A patient presented following being injured in the left eye by a fuchsia plant. Data was collected by slit lamp examination and review of the case notes and microbiology reports. Results: No organisms were cultured from a corneal scrape however cultures from a corneal biopsy identified cylindrocarpon species morphologically resembling Cylindrocarpon destructans. The patient responded well to topical amphotericin and clotrimazole and oral voriconazole but, developed a corneal perforation, which required an urgent tectonic penetrating keratoplasty (PKP). Despite being on topical dexamethasone and natamycin, the patient presented two months post-operatively with a corneal epithelial defect and a large hypopyon. Subsequently, the patient developed a deep corneal infiltrate and corneal vascularisation with a persistent epithelial defect. Conclusion: This is the first reported case of keratitis caused by Cylindrocarpon destructans. The case highlights: the contentious issues in the use of topical steroids following PKP and the duration of antifungal treatment both in primary infection and following PKP. Furthermore, the case accentuates a potential role for ciclosporin as an alternative to steroids following PKP.

Life Can’t Be Any Easier than This—Introduction of the Portable and Disposable V.A.C. Machines

The application of controlled levels of negative pressure on to a wound has been shown to accelerate evacuation of dead cells, debris and fluid which eventually encourages wound healing in a verity of surgical wounds. Vacuum Assisted Closure (V.A.C.) therapy—KCI Medical Limited, the terminology by which this is widely known, became popular, especially among the plastic surgery professionals in America and soon gained recognition worldwide. It is now widely used in the UK to manage and assist healing in a wide variety of wounds. Although KCI’s V.A.C. machines were the only ones on the market for a number of years, several wound management companies have now brought out their own machines and these are now known collectively as topical negative pressure therapy (TNPT). Traditional TNPT is often considered a relatively costly procedure. It is often used in patients with large wounds to facilitate dressing management and promote rapid cleaning and granulation. This may also allow them to be discharged to the community when they would otherwise remain inpatients, thereby saving bed days. Capital purchase of the machines is expensive and hospitals often rent or lease them on a short or long term basis. This can lead to difficulties in arranging the finances for discharge to the community. Subsequent dressing changes (recommended every 48 - 72 hrs) also incur high costs and involvement of the trained medical or nursing staff. As we all know;“Need is the mother of invention”. The disposable TNPT machine (V.A.C. ViaTM KCI Medical Ltd) has been introduced to help to solve these problems. It is a single use machine, inclusive of a dressing and canister and available off the shelf. It is very cost effective, easy to use and is used for small to moderate sized wounds. Senior author is using this machine which excellent results and illustrated the use of this machine with pictures in this paper.

The diagnostic conundrum in necrotizing otitis externa

Necrotizing otitis externa(NOE)is an aggressive and fast‐evolving infection of the external auditory canal.Late diagnoses and untreated cases can lead to severe,even fatal consequences and so early diagnosis and treatment are paramount.NOE is a notoriously challenging diagnosis to make.It is therefore important to understand what diagnostic modalities are available and how otolaryngologists can use them to accurately treat such an aggressive disease.This review aims to evaluate the different diagnostic options available in NOE and discuss their advantages and limitations,thus,providing an up‐to‐date picture of the multimodal approach required in the diagnosis of this disease.