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Absence of intussusceptum noted during the postevacuation USG examination. Once complete reduction was achieved, the fluid was evacuated from the colon by connecting a drainage bag to the Foley catheter. USG was performed again on the table to rule out a residual lesion and also to look for free fluid in the pelvis and the hepatorenal pouch to rule out any small perforation during reduction. USG was repeated after 12 h to look for recurrence, in the absence of which, feeds were started and the patient was discharged. Criterion for abandoning the procedure was failure to progress for 10 min on two attempts 15 min apart or any complication arising during the procedure. We follow this criteria as we believe that GA itself aids in reduction of intussusception and if two attempts have been unsuccessful at reduction, then further attempts are less likely to succeed and surgical intervention would be ideal. The data was collected in paper and pencil form and was entered into the excel sheet. The quantitative variables were described as mean and SD (standard deviation) or median and IQR (interquartile range) after checking for normality of the data. The qualitative variables were described as number and percentages. Appropriate statistical test were used to find association or correlation among variables. The data was analyzed using StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP. The p value of less than 0.05 was taken as significant. Results During the study period, we enrolled 48 patients with intussusception (M/F, 33/15; age mean = 16.75 months; range 6–60 months). The most common age at presentation was between 12 and 24 months of age. All patients presented with pain and vomiting. Twenty-one of 48 patients also had rectal bleeding. The duration of symptoms in most patients was between 24 and 48 h. USG revealed ileocolic intussusception in all patients. The complete list of demographic profile, presentation, and procedure information is shown in Table 1. Hydrostatic reduction was attempted in all patients in the OR under Chand et al. Annals of Pediatric Surgery (2021) 17:9 Page 2 of 7 GA. Complete reduction without any complication was achieved in 44 of 48 (91.6%) patients. In 3 of 48 (6.2%) patients, reduction could not be achieved by the hydrostatic technique; hence, surgical exploration was carried out immediately. The cause of irreducibility in one patient (patient A) aged 42 months was appendicocecal intussusception, in which whole of the appendix had intussuscepted into the caecum and only the tip was visible (Fig. 1). As the radiologist was sure that there was incomplete reduction, surgical exploration was performed and the intussusception was manually disimpacted and appendicectomy was done. In the second patient (patient B) aged 18 months, there was Meckel’s diverticulum causing ileo-ileo colic intussusception which could not be reduced by hydrostatic method. This diagnosis also was made intraoperatively after a failed hydrostatic reduction. In this patient, Meckel’s diverticulum was excised and end-to-end ileo-ileal anastomosis was performed. In the third patient (patient C) aged 60 months, after failed reduction, a laparotomy was performed and a polyp was found in the terminal ileum which looked suspicious so excision of ileal segment was done, which on histopathological examination was diagnosed as non-Hodgkin’s lymphoma. In 1 of 48 (2%) patients (patient D) who was 6 months old, the intussusception could not be reduced (Fig. 2) as there was a colonic perforation while attempting hydrostatic reduction (Fig. 3). This patient was immediately managed with surgical exploration, resection of the intussusception, and repair of colonic perforation. The complete list of demographic profile, presentation, and procedure information of these four patients is shown. LYMPHOVENOUS BYPASS “We’re excited about this technique because it can have the potential to help a lot of people with not a lot of downside for the patient.” In the outpatient operation performed at Johns Hopkins, the lymphatic system is rerouted to the venous system. 4 | Plastic and Reconstructive Surgery On the Forefront of Breast Reconstruction The department’s breast reconstruction program has taken on multiple initiatives. There’s patient safety, where groups of nurses, physicians, allied health professionals, epidemiology and infection specialists, patient safety specialists, and administrators make up a CUSP team (Comprehensive Unit-based Safety Program) to generate ideas to improve patient care and bring down patient infection rates and lengths of stay. There’s clinical research into the effects of radiation treatment on various breast reconstruction procedures and its impact on patient quality of life at various points along the process. There are advanced and technically demanding procedures like DIEP (deep inferior epigastric perforators) flap and fat grafting, also known as lipo-filling and fat-transfer, which help to rebuild the breast and surrounding areas following mastectomy and which are available widely only in select institutions. “It’s important for us to be leaders in making the patient experience and patient care world-class,” says Gedge Rosson, director of breast reconstruction and the microsurgery fellowship program. Amid all this innovation, what remains perhaps most unique is the department’s ongoing commitment to personalizing the experience for patients. It’s not just about the ability to provide the most advanced techniques, but about getting to know every patient and matching each with the reconstruction that best fits his or her own life circumstances and recovery expectations, says Michele Manahan, the department’s director of patient safety. “Our role is to rebuild to what a patient wants to be,” Manahan says. “It’s like fashion: what one person thinks is pretty, another doesn’t. We find out a patient’s wants and goals and apply our technology and skills to that.” Restoring Form and Function: Oncologic Reconstruction Oncologic reconstruction is the epitome of a team effort. Plastic surgeons collaborate with a multitude of other specialists, supporting the most appropriate oncologic treatment with cutting-edge reconstructive techniques. The goal is patient outcomes that maximize both form and function. As any surgeon knows, when resecting a tumor, it’s often impossible to avoid nerves, bone and muscle. In some cases, the tumor could not be removed unless surgical oncologists can count on reconstructive surgeons to rebuild what they must destroy. So with plastic surgeons at the table from the start, each procedure is planned and executed to ensure that patients with cancer leave not just free of the disease, but also at their highest possible level of physical functioning. Plastic surgery team members at Johns Hopkins attend regular tumor board and multidisciplinary clinic meetings to discuss cases with their interdepartmental colleagues. For example, when a patient presents with a sarcoma that’s invading the spinal cord, the physicians plan the resection that will best address removal of the tumor and simultaneously devise the reconstruction of the affected bone, muscle, tissue and blood vessels. The reconstructive team regularly collaborates with colleagues in urology, vascular surgery, surgical oncology, orthopaedic oncology, neurology, radiation oncology, gynecology, and physical medicine and rehabilitation, combining the highest level of cancer treatment with the most advanced surgical and microsurgical techniques. This approach treats the disease while preserving, or even enhancing, the patient’s wholeness, says oncological reconstruction director Justin Sacks. The department has made interdepartmental collaboration a centerpiece of its oncologic reconstruction efforts, and some faculty members consider it the essence of their work. “You’re getting the most sophisticated cancer surgery known to man,” Sacks says. Restoring Wholeness Through Reconstructive Surgery ONCOLOGIC RECONSTRUCTION “You’re getting the most sophisticated cancer surgery known to man.” Plastic and Reconstructive Surgery | 5 I n a span of just five years, the department has protocols approved and in place for hand, face and penile transplants—an indication of just how quickly its transplant portfolio has grown, and how the entire field has evolved. “Transplant is now accepted as a bona fide tool to restore both form and function in patients with devastating damage and tissue loss,” says Gerald Brandacher, scientific director of the reconstructive transplantation program. Hand Transplant Two patients in particular illustrate the dramatic effect reconstructive transplantation can have. Brendan Marrocco, severely injured in a 2009 roadside bomb attack in Iraq, was the first American soldier to survive losing all four limbs on the battlefield. In 2012, department surgeons led one of the nation’s most extensive and complicated bilateral arm transplants to give Marrocco two new arms. Today, he drives a truck, performs all activities of daily living and is preparing to move into his own home. “That represents independence, freedom and quality of life,” says Jaimie
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