No abstract

Submandibular trauma is rare, particularly in children or with an intact mandible. Clinical assessment of a child with a neck mass may need to be supplemented by diagnostic imaging. The optimal management of submandibular abscess is unclear, but an initially conservative approach is recommended. We report a case of a 10-year-old girl with a blunt injury 2 days following a fall who presented with a fever and a large lateral neck swelling. Inflammatory markers were raised and antibiotics were commenced. A magnetic resonance imaging (MRI) scan led to an initial working diagnosis of a submandibular abscess. Over time she remained systemically well, and an ultrasound could not radiologically differentiate infection from a collection. The final diagnosis was a submandibular post-traumatic hematoma with a secondarily infected collection. The initial management and decision to transfer to a higher level of service was significantly aided by the availability of MRI scanning. This case report illustrates the diagnostic and therapeutic dilemma in evaluating and treating acute mandibular swelling following blunt trauma.

Aims This systematic review and network meta-analysis evaluates the evidence for the techniques for oesophagogastric (OG) anastomosis and their impact on perioperative outcomes. Background Current evidence on the benefits of different anastomotic techniques (hand-sewn (HS), circular stapled (CS), triangular stapler (TS) or linear stapler/semi-mechanical (LSSM) techniques after oesophagectomy is conflicting. Methods A systematic literature search was conducted to identify randomised and non-randomised studies reporting techniques for the OG anastomosis. Network meta-analysis of postoperative anastomotic leaks and strictures was performed. Results This study included 15 randomised and 22 non-randomised studies (n=8,618). LSSM (OR: 0.49, CI95%: 0.33 - 0.74, p=0.001) and CS (OR: 0.68, CI95%: 0.48 - 0.95, p=0.027) and anastomoses were associated with lower anastomotic leak rates than HS anastomosis. LSSM anastomosis was found to be superior to CS (OR: 0.15, CI95%: 0.08 - 0.28, p <0.001), TS (OR: 0.32, CI95%: 0.19 - 0.54, p <0.001) and HS (OR: 0.15, CI95%: 0.05 - 0.46, p=0.001) anastomoses respectively in anastomotic stricture rates. LSSM was ranked the best technique with high probability for anastomotic leaks and strictures. Conclusions Stapled anastomoses, specifically LSSM were associated with lower anastomotic leaks and strictures rates following oesophagectomy. Therefore, current evidence suggests superiority of the LSSM technique for OG anastomosis.

Introduction Anastomotic leaks (AL) are a major complication after oesophagectomy. This meta-analysis aimed to determine identify risks factors for AL (pre-operative, intra-operative and post-operative factors) and assess the consequences to outcome on patients who developed an AL. Methods This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 31st December 2018. A meta-analysis was conducted with the use of random-effects modelling and prospectively registered with the PROSPERO database (Registration CRD42018130732). Results This review identified 174 studies reporting outcomes of 74,226 patients undergoing oesophagectomy. The overall pooled AL rates were 11%, ranging from 0 - 49% in individual studies. Majority of studies were from Asia (n=79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99 - 6.89, p<0.001) and cardiac complications (OR: 2.44, CI95%: 1.77 - 3.37, p<0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10 - 21 days, p<0.001 and in-hospital mortality (OR: 5.91, CI95%: 1.41 - 24.79, p=0.015). Conclusion AL are a major complication following oesophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL which can be a target for interventions to reduce anastomotic leak rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counselling and informed consent.