Chylothorax: An assessment of current surgical management

INTERNATIONAL ABSTRACTS

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Hypertension and Proteinuria 11 years after Nephrectomy for Wilms Tumor ....................... Urologic Complications in Menkes' Kinky Hair Disease ..............................................................

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Gonadal Effects of Cancer Therapy in Boys ........ Gonadal Effects of Cancer Therapy in Girls .......

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90 THORAX Massive Hemoptysis in Patients With Cystic Fibrosis: Three Case Reports and a Protocol for Clinical Management. A. Trento, S.M.

Musculoskeletal System Talectomy for Equinovarus Deformity in Myelodysplasia ........................................................... Split Posterior Tibial Tendon Transfers in Children With Cerebral Spastic Paralysis and Equinovarus Deformity .................................... Varus Derotation Osteotomy and Treatment of Persistent Dysplasia and Congenital Dislocation of the Hip ................................................... Sonography of the Neonatal and Infant Hip ....... Long-term Results of Sternocleidomastoid Tenotomy for Idiopathic Muscular Torticollis ......... Acute Osteomyelitis and Septic Arthritis in Children ...................................................................

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Nervous System Influence of Prognosis on Decisions Regarding Care of Newborns With Myelodysplasia ......... Review of Management Policy for Spina Bifida Newborns .......................................................... Employment of Adults With Spina Bifida ........... Use of Intraventricular Vancomycin in Treatment of CSF Shunt Associated Ventriculitis ... Comparison of Two Methods of Prophylaxis Against CSF Shunt Infection ........................... An Operative Technique to Reduce Valve Colonization ................................................................ The Tethered Spinal Cord Syndrome .................. Spinal Subdural Hematoma in an Immature Neonate After Lumbar Puncture ..................... Congenital lntraspinal Dermoid Cyst in Children ...................................................................

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Neoplasms Carcinoma In Situ of Testis in Children With 45,X/46,XY Gonadal Dysgenesis .................... Conservative Management of Testicular Endodermal Sinus Tumor in Children ...................... Endodermal Sinus Tumor of the Vagina and Cervix ................................................................ Juvenile-type Granulosa Theca Cell Tumor Producing Precocious Pseudopuberty .................... Renal Cell Carcinoma in Childhood and Adolescence ................................................................. Serum Neuron-specific Enolase in Neuroblastoma and other Pediatric Tumors ....................

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Estner, B.P. Griffith, et al. Ann Thorac Surg 39:254 256, (March), 1985. As children with cystic fibrosis survive into early adulthood, the incidence of massive hemoptysis complicating their disease has increased. The case reports of three patients (between 21 and 25 years of age) with cystic fibrosis and massive hemoptysis are included. One patient died (from exsanguination and asphyxiation) during initial bronchoscopy to identify the site of bleeding. The other two patients exemplify the recommended diagnostic and therapeutic approach to these patients. On presentation and after stabilization, bronchoscopy under general anesthesia is needed to localize the site of bleeding. This is followed by selective bronchial arteriography and arterial embolization to the appropriate vessel if spinal cord vessels are not involved. When collaterals to the spinal cord are involved, pulmonary resection is undertaken if recent pulmonary function tests confirm adequate pulmonary reserve. Yearly pulmonary function tests are recommended in all patients with cystic fibrosis to provide data for these emergent decisions.--Marleta Reynolds The Changing Spectrum of Cystic Pulmonary Lesions Requiring Surgical Resection in Infants. J.R. Schneider, J.S. St Cyr, T.R.

Thompson, et al. J Thorac Cardiovasc Surg 89:332-339, (March), 1985. Thirteen infants underwent lung resections for cystic pulmonary lesions between 1980 and 1983. Seven of the 13 were being treated for localized persistent interstitial pulmonary emphysema (IPE), an acquired cystic lesion usually involving the upper and middle lobes in premature infants with RDS and exposed to mechanical ventilation with positive end expiratory pressure. The diagnosis of IPE was made in 372 infants and required resection in only 7. The other 6 infants were treated for congenital lobar emphysema and cystic adenomatoid malformation. In those infants with IPE, operation was undertaken because of inability to be weaned from the ventilator in five patients, recurrent pneumothoraces in one patient, and atelectasis and recurrent infection in one patient. The authors conclude that IPE is now the leading cause for resection of cystic lesions in the neonate and that resection is indicated when atelectasis, presence of a decrease in effective lung volume with ventilator dependency, and persistent pneumothorax are present. All patients in this group were extubated, discharged, and have shown respiratory improvement.-Marleta Reynolds Chylothorax: An Assessment of Current Surgical Management.

J.W. Milsom, I.L. Kron, K.S. Rheuban, et al. J Thorac Cardiovasc Surg 89:221-227, (February), 1985.

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Infants comprised 16 of 20 patients with persistent chylothorax treated over a 10-year period. Five of the six patients treated nonoperatively were premature infants with superior vena caval thrombosis secondary to indwelling central venous catheters. Four of these infants expired from respiratory failure and sepsis. The sole survivor in this group had spontaneous resolution of the chylothorax after two weeks. Eleven of the 14 patients treated operatively were infants. Five premature infants were treated with pleuroperitoneal shunts, and in four it successfully eliminated the effusion. Two of these premature infants died; one from an intraventricular hemor-

INTERNATIONAL ABSTRACTS rhage and the other from progressive heart failure. Five children were treated with chylothorax following cardiovascular procedures for congenital heart disease. Thoracic duct ligation was successful in two, and in another two a pleuroperitoneal shunt was used. Two children with baffle obstruction after a Mustard procedure required intracardiac revision of the baffle. One child had thoracic duct ligation after a T E F repair. The authors recommend early nutritional support and a brief period of nonoperative therapy prior to surgical intervention. Pleuroperitoneal shunting is a relatively new option that appears to show promise for treatment of chylothorax. Marleta Reynolds Diaphragmatic Hernia in Neonate. R.J. Brereton, D. Kumar and

L. Spitz. Z Kinderchir 40:75 79, (April), 1985. The authors report on a series of 41 infants with congenital diaphragmatic hernia who underwent surgery in the neonatal period. Overall survival rate was 68%. Only four of the infants had right sided hernias, three of whom died. Survival rate was 55% in neonates who were operated on within 6 hours and 73% in those who were operated on between 6 and 24 hours after birth. All of the deaths occurred in those presenting and undergoing operations within 9 hours of birth. There were no deaths in infants who did not require ventilation prior to surgery. Whereas no correlation could be found between preoperative PCO2 levels and prognosis, survival rates were significantly higher when preoperative PO2 was over 100 mm Hg and pH over 7.2. The infants could be classified into two groups. The first group, where survival rate was 95%, did not have severe respiratory distress and had small diaphragmatic defects. The second group bad severe respiratory distress or large lesions and a survival rate of only 30%. Thomas A. Angerpointner Classification and Management of Congenital Diaphragmatic Hernia Developing Symptoms Within the First 24 Hours. M. Nagaya,

T. ~to, N. Yamada, et al. J Jap Soc Pediatr Surg 20:1161 1169, 1984. Twenty-six patients with congenital diaphragmatic hernia who developed symptoms within the first 24 hours of life were classified into three groups according to the results of blood gas analysis and their outcomes. Group 1 (9 patients): The preoperative A a D O was lower than 500 mmHg. The postoperative course in this group was uneventful without mortality. One developed persistent fetal circulation (PCF), which was cured successfully. Group 2 (8 patients): The preoperative AaDO was higher than 500 m m H g and the postoperative PaO elevated higher than 200 m m H g shortly after operation. Half of these developed PFC with three deaths. During the several hours after operation, they remained in the so-called honeymoon period and slipped into PFC with minimum stimulation. Mechanical ventilation and administration of blockers were effective in these patients with PFC. Group 3 (7 patients): The preoperative A a D O was higher than 500 m m H g , but there was no elevation of the PaO postoperatively. Neither respiratory care nor pharmacologic treatment was effective in these cases. Hypoxia in these patients might be caused by hypoplastic lung. There was no survivor in this group. The authors conclude that their classification was beneficial in managing the patients with congenital diaphragmatic hernia.--S. Suita HEART AND GREAT VESSELS Fifteen-Year Experience With Surgical Repair of Truncus Arteriosus. R.M. DiDonato, D.A. FyJe, F.J. Puga, et al. J Thorac Cardio-

vasc Surg 89:414 422, (March), 1985. One hundred sixty-seven patients have undergone complete surgical repair of truncus arteriosus at the center from 1965 to 1982. Age

85 at operation ranged from 18 days to 33 years with a mean of 6 years. Early palliation with pulmonary artery banding was provided in 57. Hospital mortality was 28.7%. Age at operation less than two years, a post repair pulmonary arterial/left ventricular pressure ratio greater than 0.5 for patients with two pulmonary arteries and more than 0.6 for those with one pulmonary artery, and a post repair R V / L V pressure ratio of more than 0.8 correlated with early death. At five years, 84.4% were alive and at ten years 68.8%. Extra cardiac conduit replacement was required in 32 patients; 15 for obstruction of calcified aortic homografts, 11 for obstruction of porcine valved conduits, and six with complex reoperations that included replacement of the conduit. Reoperation was responsible for eight of the 29 late deaths. Decreased long-term survival correlated with increasing age at operation, moderate to severe truncal valve insufficiency, lower Qp/Q~ ratio, and unilateral absence of a pulmonary artery. The extended period of time involved with the evolution of the surgical repair for truncus arteriosus allows for comparison of each age group as repairs were done earlier. The results support the contention that repair should be done earlier and that late survival will depend, in part, on advances in conduit construction and techniques to prevent truncal valve insufficiency--Marleta Reynolds Should Elective Repair of Coarctation of the Aorta Be Done in Infancy? D.B. Campbell, J.A. Waldhausen, W.S. Pierce, et al. J

Thorac Cardiovasc Surg 88:929-938, (December), 1984. Thirty-five infants with coarctation of the aorta were repaired with the subclavian flap technique. Preoperative stabilization with prostaglandin infusions, diuretics, and inotropic drugs helped to reduce the operative mortality to 4%. Follow-up studies with a mean of 46 months have revealed a persistent gradient in 4%. The use of monofilament absorbable suture appears to further reduce the incidence of recoarctation. The late cardiovascular complications that occur in children who are repaired later in life can be avoided when repair is done in infancy. This, in addition to the very low associated morbidity and mortality, strengthens the argument for early repair of coarctation in infancy Marleta Reynolds C o a r c t a t i o n of t h e Aorta in Infants. J.L. Harlan, D.B. Doty, B.

Brandt, 111, et al. J Thorac Cardiovasc Surg 88:1012 1019, (December), 1984. A twenty-year series of 47 consecutive infants with coarctation of the aorta repaired at less than one year of age provides comparison of the use of different suture material. Resection of the coarctation with end-to-end anastomosis to the distal aortic arch was done in 43 and patch angioplasty in four. Since 1972, polypropylene suture has replaced silk suture for the anastomosis, and actuarial freedom from recurrence at five and ten years has improved from 57% and 44% in the silk group to 91% in the polypropylene group. Sacrifice of the subclavian artery is prevented by this technique, and the need for prosthetic material in other angioplastic procedures is avoided. Marleta Reynolds Coarctation of the Aorta in Patients Younger Than Three Months: A Critique of the Subclavian Flap Operation. A. Cohanog/u, J.E.

Tepley, G.L. Grunkemeier, et al. J Thorac Cardiovasc Surg 89:128135, (January), 1985. Infants less than three months of age with coarctation of the aorta were treated with two different surgical procedures from 1960 to 1983. Fifty-five infants had end-to-end anastomosis and 67 subclavian angioplasty. Operative mortality was not significantly different between the two groups. Reoperation was required in ten patients with subclavian flap angioplasty, and in eight the early recurrence