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Iatrogenic causes of large pleural fluid collections in the premature infant: Ultrasonic and radiographic findings
INTERNATIONAL ABSTRACTS
an index on ventilation (VI = mean airway pressure X respiratory rate) and confirmed by postmortem analysis of the lung. Those infants were PaCOz >40 mmHg before surgery had a 77% mortality. When P a C e 2 reduction could be achieved only with VI > 1,000, the mortality was still >50%. After repair, however, the ability to hyperventilate to P a C e 2 <40 mmHg proved to be an important determinant of survival. Only one of 31 infants in this group died, whereas only two of 27 infants with PaCe2 >40 mmHg survived. In 16 infants with P a C e 2 >40 mmHg despite hyperventilation, highfrequency oscillatory ventilation was started. This resulted in a rapid fall in PaCe2, but 14 of the 16 infants had only temporary improvement in oxygenation and died. In five of the infants who died, alveolar number was assessed by postmortem morphometric analysis. There was a severe reduction to < 10% of published normal neonatal values. Pulmonary vascular changes of increased muscularization were less remarkable than those observed in infants with persistent pulmonary hypertension. These findings suggest that the degree of pulmonary hypoplasia (which would not be influenced by surgical repair), rather than the pulmonary vascular abnormality, mainly determines survival. Consideration might, therefore, be given to an initial nonsurgical approach to congenital diaphragmatic hernia with the expectation that pulmonary function might improve and pulmonary vascular resistance decrease.--George Holcornb, j r
493
evaluated the role of the chest radiograph, high kV films, CT, and bronchoscopy in five patients with congenital tracheal stenosis. CT was superior to chest radiography and high kV films in the evaluation of the presence and extent of the stenosis. CT was superior to bronchoscopy in the evaluation of the distal extent of the stenosis in two patients. In addition, CT is useful in ruling out external compression of the trachea by a mass or associated vascular anomaly. Prem Puri latrogenic Causes of Large Pleural Fluid Collections in the Premature Infant: Ultrasonic and Radiographic Findings. J. Amodio, S.
Abramson, I,IL. Berdon, et al. Pediatr Radiol 17:104-108, (February), 1987. Ten cases of large pleural collections, all of which were iatrogenically induced in premature infants, are presented. There were five instances of hypopharyngeal tears communicating with the right pleural space, three of chylothorax secondary to superior vena caval obstruction in patients undergoing total parenteral nutrition catheterization (TPN), and two of direct erosion by the inferior vena caval TPN catheter into the pleural space. Ultrasonography was most helpful in detecting these pleura/ collections. It is important to recognize the presence of pleural fluid in these infants as a marker of iatrogenic injury.--Prem Puri
Effects of Surgical Repair on Respiratory Mechanics in Congenital Diaphragmatic Hernia. H. Sakai, M. Tamura, Y. Hosokawa, et al. J
Pediatr 111:432-438, (September), 1987. To determine whether surgical repair of congenital diaphragmatic hernia (CHD) results in improvement in respiratory mechanics, the respiratory system compliance was measured in nine patients (five survivors and four nonsurvivors) before and after operation. In all nine infants, CHD was diagnosed within six hours of life, and surgical repair was through an abdominal approach after a period of stabilization. Measurements were made noninvasively using the passive expiratory flow-volume technique. In only one of the nine infants did compliance immediately improve after surgical repair, and in another it showed no change. Both of these infants survived, with an uneventful postoperative course. In the remaining seven infants, however, postoperative compliance immediately decreased from 10% to 77% from the preoperative value. The four infants with more than 50% decrease in compliance died with increasing hypoxemia and acidosis, These results suggest that respiratory mechanics in CHD, far from improving, frequently deteriorate as a result of repair of the hernia. The role of urgent surgery in this malformation should be reevaluated.--George Holcomb, Jr The Spectrum of Bronchopulmonary Foregut Malformations. N.
McMullin, O. Doi, and M. Kent. Pediatr Surg Int 2:304-306, (September), 1987. Bronchogenic cysts and pulmonary sequestrations have in the past been defined as separate congenital pathologic entities. The association of both in one mediastinal lesion is very rare. Such a case is reported and lends support to the concept that bronchogenic cysts and pulmonary sequestrations belong in a spectrum of bronchopulmonary malformations due to abnormal ventral budding of the primitive foregut. Their exact position in the spectrum is probably dependent on several independent key embryologic events.--Prem Puri Congenital Tracheal Stenosis: Role of CT and High kV Films. R.J. Hernandez and G.F. Tucker. Pediatr Radiol 17:192-196, (March), 1987.
Congenital tracheal stenosis is an intrinsic narrowing of the tracheal lumen due to complete cartilaginous rings. The authors
ALIMENTARY TRACT The Embryology of Usual and Unusual Types of Esophageal Atresia. D. Kluth and R. Habenicht. Pediatr Surg lnternat 2:223-227,
(July), 1987. Despite various theories, the pathogenesis of esophageal atresia is still unclear. The investigations of recent years seem to indicate that the leading role of the "septum tracheoesophageale" in normal and abnormal development of the foregut must be questioned. In this paper, new concepts of the pathogenesis of esophageal atresia are discussed with special consideration of the "unusual" types of atresia.--Prem Puri Treatment of Type A Esophageal Atresia Without Gastrostomy.
M. Carcassonne, M. Coquet and B. Kreitmann. Chirurgie 112:743745, (December), 1986. From 1973, gastrostomy had been omitted in the treatment of type A esophageal atresia. Two series were analyzed at the French Academy of Surgery: one in 1981 and the last one in 1986, From 1981 to 1986, of 54 patients, 39 were operated on without gastrostomy. No mortality was observed. The initial and late follow-up was uncomplicated. In 11 Waterston group C patients a gastrostomy was used. Three early deaths and one later death are reported. Gastrostomy is no longer considered useful in patients in good condition. Improvement of preoperative respiratory treatment should diminish the use of gastrostomy even in group C esophageal atresia.--J.M. Guys Oesophageal Atresia With Proximal Tracheo-oesophageal Fistula.
D. Cass and A. Auldist. Pediatr Surg Internat 2:212-215, (July), 1987. Esophageal atresia with proximal tracheoesophageal fistula is an uncommon subgroup comprising 2% of infants with esophageal atresia. Of those infants with esophageal atresia presenting with a gasless abdomen on initial abdominal x-ray, 23.5% had esophageal atresia with proximal tracheoesophageal fistula, and these infants thus warrant a careful study of the upper esophagus. The fistula may be difficult to demonstrate and the early appearance of contrast material in the trachea may be misinterpreted as due to aspiration or "spillover." All cases were treated differently, but a plan of manage-
an index on ventilation (VI = mean airway pressure X respiratory rate) and confirmed by postmortem analysis of the lung. Those infants were PaCOz >40 mmHg before surgery had a 77% mortality. When P a C e 2 reduction could be achieved only with VI > 1,000, the mortality was still >50%. After repair, however, the ability to hyperventilate to P a C e 2 <40 mmHg proved to be an important determinant of survival. Only one of 31 infants in this group died, whereas only two of 27 infants with PaCe2 >40 mmHg survived. In 16 infants with P a C e 2 >40 mmHg despite hyperventilation, highfrequency oscillatory ventilation was started. This resulted in a rapid fall in PaCe2, but 14 of the 16 infants had only temporary improvement in oxygenation and died. In five of the infants who died, alveolar number was assessed by postmortem morphometric analysis. There was a severe reduction to < 10% of published normal neonatal values. Pulmonary vascular changes of increased muscularization were less remarkable than those observed in infants with persistent pulmonary hypertension. These findings suggest that the degree of pulmonary hypoplasia (which would not be influenced by surgical repair), rather than the pulmonary vascular abnormality, mainly determines survival. Consideration might, therefore, be given to an initial nonsurgical approach to congenital diaphragmatic hernia with the expectation that pulmonary function might improve and pulmonary vascular resistance decrease.--George Holcornb, j r
493
evaluated the role of the chest radiograph, high kV films, CT, and bronchoscopy in five patients with congenital tracheal stenosis. CT was superior to chest radiography and high kV films in the evaluation of the presence and extent of the stenosis. CT was superior to bronchoscopy in the evaluation of the distal extent of the stenosis in two patients. In addition, CT is useful in ruling out external compression of the trachea by a mass or associated vascular anomaly. Prem Puri latrogenic Causes of Large Pleural Fluid Collections in the Premature Infant: Ultrasonic and Radiographic Findings. J. Amodio, S.
Abramson, I,IL. Berdon, et al. Pediatr Radiol 17:104-108, (February), 1987. Ten cases of large pleural collections, all of which were iatrogenically induced in premature infants, are presented. There were five instances of hypopharyngeal tears communicating with the right pleural space, three of chylothorax secondary to superior vena caval obstruction in patients undergoing total parenteral nutrition catheterization (TPN), and two of direct erosion by the inferior vena caval TPN catheter into the pleural space. Ultrasonography was most helpful in detecting these pleura/ collections. It is important to recognize the presence of pleural fluid in these infants as a marker of iatrogenic injury.--Prem Puri
Effects of Surgical Repair on Respiratory Mechanics in Congenital Diaphragmatic Hernia. H. Sakai, M. Tamura, Y. Hosokawa, et al. J
Pediatr 111:432-438, (September), 1987. To determine whether surgical repair of congenital diaphragmatic hernia (CHD) results in improvement in respiratory mechanics, the respiratory system compliance was measured in nine patients (five survivors and four nonsurvivors) before and after operation. In all nine infants, CHD was diagnosed within six hours of life, and surgical repair was through an abdominal approach after a period of stabilization. Measurements were made noninvasively using the passive expiratory flow-volume technique. In only one of the nine infants did compliance immediately improve after surgical repair, and in another it showed no change. Both of these infants survived, with an uneventful postoperative course. In the remaining seven infants, however, postoperative compliance immediately decreased from 10% to 77% from the preoperative value. The four infants with more than 50% decrease in compliance died with increasing hypoxemia and acidosis, These results suggest that respiratory mechanics in CHD, far from improving, frequently deteriorate as a result of repair of the hernia. The role of urgent surgery in this malformation should be reevaluated.--George Holcomb, Jr The Spectrum of Bronchopulmonary Foregut Malformations. N.
McMullin, O. Doi, and M. Kent. Pediatr Surg Int 2:304-306, (September), 1987. Bronchogenic cysts and pulmonary sequestrations have in the past been defined as separate congenital pathologic entities. The association of both in one mediastinal lesion is very rare. Such a case is reported and lends support to the concept that bronchogenic cysts and pulmonary sequestrations belong in a spectrum of bronchopulmonary malformations due to abnormal ventral budding of the primitive foregut. Their exact position in the spectrum is probably dependent on several independent key embryologic events.--Prem Puri Congenital Tracheal Stenosis: Role of CT and High kV Films. R.J. Hernandez and G.F. Tucker. Pediatr Radiol 17:192-196, (March), 1987.
Congenital tracheal stenosis is an intrinsic narrowing of the tracheal lumen due to complete cartilaginous rings. The authors
ALIMENTARY TRACT The Embryology of Usual and Unusual Types of Esophageal Atresia. D. Kluth and R. Habenicht. Pediatr Surg lnternat 2:223-227,
(July), 1987. Despite various theories, the pathogenesis of esophageal atresia is still unclear. The investigations of recent years seem to indicate that the leading role of the "septum tracheoesophageale" in normal and abnormal development of the foregut must be questioned. In this paper, new concepts of the pathogenesis of esophageal atresia are discussed with special consideration of the "unusual" types of atresia.--Prem Puri Treatment of Type A Esophageal Atresia Without Gastrostomy.
M. Carcassonne, M. Coquet and B. Kreitmann. Chirurgie 112:743745, (December), 1986. From 1973, gastrostomy had been omitted in the treatment of type A esophageal atresia. Two series were analyzed at the French Academy of Surgery: one in 1981 and the last one in 1986, From 1981 to 1986, of 54 patients, 39 were operated on without gastrostomy. No mortality was observed. The initial and late follow-up was uncomplicated. In 11 Waterston group C patients a gastrostomy was used. Three early deaths and one later death are reported. Gastrostomy is no longer considered useful in patients in good condition. Improvement of preoperative respiratory treatment should diminish the use of gastrostomy even in group C esophageal atresia.--J.M. Guys Oesophageal Atresia With Proximal Tracheo-oesophageal Fistula.
D. Cass and A. Auldist. Pediatr Surg Internat 2:212-215, (July), 1987. Esophageal atresia with proximal tracheoesophageal fistula is an uncommon subgroup comprising 2% of infants with esophageal atresia. Of those infants with esophageal atresia presenting with a gasless abdomen on initial abdominal x-ray, 23.5% had esophageal atresia with proximal tracheoesophageal fistula, and these infants thus warrant a careful study of the upper esophagus. The fistula may be difficult to demonstrate and the early appearance of contrast material in the trachea may be misinterpreted as due to aspiration or "spillover." All cases were treated differently, but a plan of manage-