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Patient A Patient B Patient C Patient D Reason for surgical intervention Failed reduction Failed reduction Failed reduction Bowel perforation Intraoperative finding Appendicocecal intussusception Meckel’s diverticulum Hodgkin’s lymphoma Colonic perforation and necrotic intussusceptum Age (months) 42 18 60 6 Duration of symptoms (hours) 48 38 36 72 Clinical presentation Pain Vomiting Pain Vomiting Rectal bleeding Pain Vomiting Pain Vomiting Rectal bleeding Volume of fluid used 2000 ml 2000 ml 2000 ml 1000 ml Surgical management Manual reduction and appendectomy Resection of Meckel’s and end-to-end anastomosis Resection of ileal segment and end-to-end anastomosis Resection of devitalized intussuscepted gut, end-toend anastomosis, and primary repair of colonic perforation Post-surgical complications Nil Nil Nil Nil Chand et al. Annals of Pediatric Surgery (2021) 17:9 Page 5 of 7 We consider the treatment of intussusception to be constituted of three arms. First is the “counterforce” (fluid, air or manual). The second is an “observer” who is the radiologist (USG/fluoroscopy), and the third arm is a “fallback team” comprising of the pediatric surgeon and anesthesiologist who are to be ready in the OR for immediate surgical intervention, if needed. In almost all described techniques of non-operative reduction, only two of these three arms have been used, comprising of a surgeon and a radiologist and performed in the radiology suite. But before starting the procedure, the third arm consisting of the anesthetist and OR is always notified and in as many as 10–20% of cases where failure or complications arise may be pressed into action. We do not consider this to be the best possible treatment scenario. Trying to reduce an intussusception in the radiology suite with a child who is in pain and in the presence of anxious parents leads to added stress to the patient and the parents. The surgeon performing the procedure in the radiology suite is concerned of the possibility of failure of reduction, of causing perforation, and whether the OR would be readily available without any delay, if needed. The apprehensions of the surgeon and the parents can be allayed by performing the procedure in the OR under GA with the surgical team ready for any eventuality. The contention of risk of GA and need for anesthesiologist is unsubstantiated as sedation in radiology suite with limited resources and the risk of aspiration itself warrants for the procedure to be done under the care of an anesthesiologist preferably in the OR. Sedatives usually given during such procedures are benzodiazepines and anti-cholinergics combined with ketamine or fentanyl, doses of which may have to be increased many folds if the procedure is prolonged. The disadvantages of sedation in children can be due to undersedation like causing anxiety to the patient, leading to an uncooperative child, causing difficulty in hydrostatic reduction, and also leaving a psychological impact as complete amnesia is not achieved. dimensional reconstruction of the human cadabefore transplantation, after transplantation, planned outcombefore transplantation. Note the sites of rigid fixation in a Leface-jaw-teeth transplantation. The red dots denote the memark positions in each model (below). Frontal three-dimensional reconstruction of the human cadaver recipient post-facial transplantation (top) using real-time cephalometry and computer-assisted technology versus the planned outcome (bottom). Of note, the red dots denote the measured landmark positions used for cephalometric analysis and technology development. Volume 136, Number 2 • Hybrid Occlusion and Cephalometry experiment, which did not show any deviations greater than 3 mm or 2 degrees from target measurements (Table 5). The plastic model experiment represents an idealized procedure with highly accurate patient-to-model registration error (0.727 mm and 0.306 mm for the plastic skull model donor and recipient, compared with 1.22 mm and 0.745 mm for the human cadaver donor and recipient, respectively), leading to improved tracking of the donor fragment when placing on the recipient. This achieves improved accuracy in comparing intraoperative to postoperative cephalometric measurements. The largest error comparing planned to posttransplant measurements in the plastic skull model (B–A, 1.97 mm) is on par with the largest error exhibited by the control measure (Go–Me, 2.24 mm). As such, the plastic model experiment mayrepresentthepotentialbestcasescenarioforThe human cadaver experimenson of post–face-jaw-teeth transplaplanned outcome measurements shdifferences in Me–Na (5.98 mm), andegrees)/SNB (3.03 degrees) angleIn the comparison of predicted invalues relative to obtained postoperoverbite (3.65 mm), B–A (5.31 mm(4.38 mm), and Me–Na (5.98 mm) greatest variation (Table 5). The eated with these measurements cofrom two sources: (1) landmarktion error and (2) navigation and error. Landmark identification errothe subject of many studies.27–30 A mof several studies on landmark idand reproducibility showed totaltionerrorofapproximately081mFig. 6. Lateral view of the human cadaver before transplantation (donor and recipient), after transplantation, and the planned outcome. The red dots denote the measured landmark positions in each model (above). Frontal three-dimensional reconstruction of the human cadaver recipient before transplantation, after transplantation, planned outcome, and donor before transplantation. Note the sites of rigid fixation in a Le Fort–based face-jaw-teeth transplantation. The red dots denote the measured landmark positions in each model (below). IMAGES REPRODUCED FROM: MURPHY RJ, ET AL. PLAST RECONSTR SURG 2015 Plastic and Reconstructive Surgery | 7 Urogenital Transplant Following the success of their upper extremity reconstructive transplants, faculty members began planning to transplant a penis—something that has been attempted only twice in the world. In particular, they were hoping to benefit soldiers injured by roadside bombs, who sometimes experience damage in pelvic areas not covered by traditional body armor, and who often sustain such extensive additional injuries that surgeons are hard-pressed to find the donor sites necessary for conventional penile reconstruction. But the literature indicated that after a penis is sewn back on following a traumatic cut, the penis generally survives, but the skin dies. Enter resident physician Sami Tuffaha, whose untold hours studying the problem in the lab were rewarded by the discovery of a previously unknown blood vessel leading from the femoral artery to supply the shaft skin. “When there’s so much tissue, you need this vessel to make it work. No one knew this vessel even existed two and a half years ago,” says Richard Redett, director of the Pediatric Plastic and Reconstructive Surgery and Johns Hopkins Cleft Lip and Palate Center. Armed with this new finding, Redett’s 15 years of experience doing complex urogenital reconstructions on children, the promise of minimal immunosuppression and perhaps the most experienced reconstructive transplant program in the country, faculty members have been practicing all the details of the procedure. With the collaboration of specialties, including urology, psychiatry and psychology, bioethics, and transplant immunology, the team hopes to complete the first penile transplant in the near future. “You can only imagine the impact a penile amputation would have on a young man in his early 20s, who’s been serving overseas and returns from service to the civilian world and all prospects of a normal social and sexual life have been taken away from him,” says reconstructive surgeon Damon Cooney. “We want to do whatever we can to help him return to manhood and wholeness, and also urinary and sexual function.” “We want to do whatever we can to help him return to manhood and wholeness, and also urinary and sexual function.” Illustration depicting penile transplantation ILLUSTRATION BY TIM PHELPS Exploring the Vanguard of Transplantation: Hand, Face and Urogenital RECONSTRUCTIVE TRANSPLANT 8 | Plastic and Reconstructive Surgery W. P. Andrew Lee, M.D. The Milton T. Edgerton, M.D., Professor and Director Department of Plastic and Reconstructive
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