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Long-gap esophageal atresia: Experience with reconstruction in 25 patients
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tional assisted ventilation during a 48-hour delay before surgery, and survived. In all, 8 of 9 infants who underwent preoperative stabilization survived (P < .05 compared with survival after emergency surgery). Following surgical repair immediately after birth, respiratory system compliance improved only slightly during the first week of life, a time when control infants had a rapid increase in respiratory system compliance (P < ,001). In contrast, respiratory system compliance increased nearly twofold in the 9 patients undergoing preoperative stabilization (P < .02). Preoperative ECMO was associated with an increase in respiratory system compliance of more than 60% for 1 week, a significant difference from respiratory system compliance among patients undergoing emergency CDH repair (P < .OS). These observations provide physiological evidence of possible benefits of preoperative stabilization before repair of CDH.-George Holcomb, Jr Surgical Correction of Hydrothorax From Diaphragmatic Eventration in Children on Peritoneal Dialysis. H.S. Bjerke, ES. Adkins, and R.P. Foglia. Surgery 109550-554, (April), 1991. This report addresses the 2% of children on continuous ambulatory peritoneal dialysis (CAPD) who develop massive unilateral hydrothorax. This complication usually results in the discontinuation of peritoneal dialysis. The report describes three patients who received CAPD and had massive hydrothoraces. Two patients had right hydrothoraces; one presented with a left hydrothorax. Diaphragmatic eventrations were found in all, located in the central segment of the diaphragm. These were plicated with nonabsorbable suture, and the children were returned to peritoneal dialysis. The authors suggest an algorithm for treatment of this complication. Following appropriate nuclear medicine and/or radiographic studies, decreased dialysate volumes may resolve the problem. Repeated thoracentesis has been effective in adults but is not well tolerated in children. Therefore, if volume trials are not successful, thoracotomy with correction of the diaphragmatic abnormality can be curative.-Thomas F. Tracy, Jr
HEART AND GREAT VESSELS Continuous Extracorporeal Fluid Removal in Children With Low Cardiac Output After Cardiac Operations. G. Zobel, J.I. Stein, M Kuttnig, et al. J Thorac Cardiovasc Surg 101:593-597, (April), 1991. Eleven children were treated with continuous ultrafiltration or arteriovenous hemohltration following cardiac operations. All were hypervolemic and oliguric with low cardiac output. Negative fluid balance significantly improved hemodynamic status in these patients within 59 ? 6.1 hours (SEM). Significant decreases in central venous pressure were accompanied by increases in the mean arterial pressure and arterial pH. With these improvements, significant decreases in catecholamine infusion rates were found. This method of treatment was complicated by persistent anuria in four children after achieving normovolemia, and two patients died without recovery of renal function. These reports parallel previous reports of the use of ultrafiltration in patients undergoing treatment by extracorporeal membrane oxygenation, and demonstrate the significant complication of anuria following ultrafiltration, which has been attributed in other experimental studies to significant decreases in renal blood flow during hemofiltration.-Thomas F. Tracy. Jr Atieriovenous Fistula Between Descending Aorta and Hemiazygos Vein. P.G. Gamba. M. Longo, G.F. Zanon, ef al. Eur J Pediatr Surg 1:49-50, (February), 1991. This article describes a rare case of congenital atrioventricular (AV) tistula between descending aorta and hemiazygos vein in a
ABSTRACTS
9-year-old girl. She presented with repeated episodes of bronchitis, and a detailed study was performed to elucidate their etiology. Angiography disclosed an AV fistula at the site described above. The fistula was ligated twice and divided. Postoperative course was uneventful. Differential diagnosis in these cases is difficult. Only sonography and angiography can provide a correct diagnosis. The recent literature on this subject is reviewed.-ThomnsA. Angelpointner Complete External Iliac Artery Disruption After Percutaneous Aortic Valvuloplasty in Two Young Children: Successful Repair With Hypogastric Artery Transposition. D.F. Cikrit, M.A. Helikson, W.K. Nichols. et al. Surgery 109:623-626, (May), 1991. Percutaneous transluminal valvuloplasty (PTV) has been used more frequently as a treatment modality for aortic and pulmonary valvular stenosis in children. Vascular injuries in these children have included perforation at the dilatation site and thrombosis at the cutaneous puncture site. This report documents the first two cases of complete external iliac artery disruption that followed PTV. Both children had evidence of a hemorrhage and/or retroperitoneal hematoma following removal of large 9F balloon catheters. Both injuries were on the right side and were approached through retroperitoneal incisions. Once proximal and distal control were obtained in these hypotensive patients, the right hypogastric artery was mobilized and spatulated end-to-end anastomoses performed with 6-O polypropylene interrupted sutures. Both children were doing well 1 year postoperatively with normal pulses and limb growth. The authors add this significant iatrogenic injury to a group of injuries that are the most common cause of arterial ischemia in infants and young children. They advise that prompt recognition and surgical correction are necessary to ensure normal limb growth and development.-Thomas F. Tracy. Jr
ALIMENTARY
TRACT
Long-Gap Esophageal Atresia: Experience With Reconstruction in 25 Patients. C. Festen, P.N.M.A. Rieu, F.H.J.M. van der Stuak, etaf. Eur J Pediatr Surg 1:139-141, (June), 1991. The authors report a series of 183 patients operated on for esophageal atresia in a ZO-year period, 25 of whom had a long-gap atresia that precluded immediate primary anastomosis. There were 11 boys and 14 girls. Multiple anomalies were diagnosed in 15 of the 2.5 infants. Eighteen patients were treated by proximal pouch stretching with the intention of doing a delayed primary anastomosis; five were treated by the Rehbein “thread technique”: and two patients underwent colonic interposition. The overall survival rate was 80%, which compares favorably with the results of esophageal replacement reported in the literature.-Thomas A. Angerpointner Congenital Esophagostenosis. R. Merger, M. Miiller, F. Sennhauser, ef al. Eur J Pediatr Surg 1:142-144, (June), 1991. The incidence of congenital esophagostenosis is 1 in 50,000 live births. Two patients with this very rare entity are reported. Clinical signs are frequent vomiting, regurgitation of undigested food without acid smell, and regurgitation of viscous mucus and saliva. Both patients underwent surgical repair. It is suggested that primary operation should replace bougienage treatment formerly in use.Thomas A. AngeTointner Esophageal pH Monitoring: Methodology, Indication and Interpretation. Y. Vundenplas. Eur J Pediatr Surg 1:67-72, (April), 1991. Gastroesophageal reflux (GER) may be considered as a cause of esophagitis, failure to thrive, and anemia. However, it is also recognized as a physiological phenomenon occurring especially in
INTERNATIONAL
tional assisted ventilation during a 48-hour delay before surgery, and survived. In all, 8 of 9 infants who underwent preoperative stabilization survived (P < .05 compared with survival after emergency surgery). Following surgical repair immediately after birth, respiratory system compliance improved only slightly during the first week of life, a time when control infants had a rapid increase in respiratory system compliance (P < ,001). In contrast, respiratory system compliance increased nearly twofold in the 9 patients undergoing preoperative stabilization (P < .02). Preoperative ECMO was associated with an increase in respiratory system compliance of more than 60% for 1 week, a significant difference from respiratory system compliance among patients undergoing emergency CDH repair (P < .OS). These observations provide physiological evidence of possible benefits of preoperative stabilization before repair of CDH.-George Holcomb, Jr Surgical Correction of Hydrothorax From Diaphragmatic Eventration in Children on Peritoneal Dialysis. H.S. Bjerke, ES. Adkins, and R.P. Foglia. Surgery 109550-554, (April), 1991. This report addresses the 2% of children on continuous ambulatory peritoneal dialysis (CAPD) who develop massive unilateral hydrothorax. This complication usually results in the discontinuation of peritoneal dialysis. The report describes three patients who received CAPD and had massive hydrothoraces. Two patients had right hydrothoraces; one presented with a left hydrothorax. Diaphragmatic eventrations were found in all, located in the central segment of the diaphragm. These were plicated with nonabsorbable suture, and the children were returned to peritoneal dialysis. The authors suggest an algorithm for treatment of this complication. Following appropriate nuclear medicine and/or radiographic studies, decreased dialysate volumes may resolve the problem. Repeated thoracentesis has been effective in adults but is not well tolerated in children. Therefore, if volume trials are not successful, thoracotomy with correction of the diaphragmatic abnormality can be curative.-Thomas F. Tracy, Jr
HEART AND GREAT VESSELS Continuous Extracorporeal Fluid Removal in Children With Low Cardiac Output After Cardiac Operations. G. Zobel, J.I. Stein, M Kuttnig, et al. J Thorac Cardiovasc Surg 101:593-597, (April), 1991. Eleven children were treated with continuous ultrafiltration or arteriovenous hemohltration following cardiac operations. All were hypervolemic and oliguric with low cardiac output. Negative fluid balance significantly improved hemodynamic status in these patients within 59 ? 6.1 hours (SEM). Significant decreases in central venous pressure were accompanied by increases in the mean arterial pressure and arterial pH. With these improvements, significant decreases in catecholamine infusion rates were found. This method of treatment was complicated by persistent anuria in four children after achieving normovolemia, and two patients died without recovery of renal function. These reports parallel previous reports of the use of ultrafiltration in patients undergoing treatment by extracorporeal membrane oxygenation, and demonstrate the significant complication of anuria following ultrafiltration, which has been attributed in other experimental studies to significant decreases in renal blood flow during hemofiltration.-Thomas F. Tracy. Jr Atieriovenous Fistula Between Descending Aorta and Hemiazygos Vein. P.G. Gamba. M. Longo, G.F. Zanon, ef al. Eur J Pediatr Surg 1:49-50, (February), 1991. This article describes a rare case of congenital atrioventricular (AV) tistula between descending aorta and hemiazygos vein in a
ABSTRACTS
9-year-old girl. She presented with repeated episodes of bronchitis, and a detailed study was performed to elucidate their etiology. Angiography disclosed an AV fistula at the site described above. The fistula was ligated twice and divided. Postoperative course was uneventful. Differential diagnosis in these cases is difficult. Only sonography and angiography can provide a correct diagnosis. The recent literature on this subject is reviewed.-ThomnsA. Angelpointner Complete External Iliac Artery Disruption After Percutaneous Aortic Valvuloplasty in Two Young Children: Successful Repair With Hypogastric Artery Transposition. D.F. Cikrit, M.A. Helikson, W.K. Nichols. et al. Surgery 109:623-626, (May), 1991. Percutaneous transluminal valvuloplasty (PTV) has been used more frequently as a treatment modality for aortic and pulmonary valvular stenosis in children. Vascular injuries in these children have included perforation at the dilatation site and thrombosis at the cutaneous puncture site. This report documents the first two cases of complete external iliac artery disruption that followed PTV. Both children had evidence of a hemorrhage and/or retroperitoneal hematoma following removal of large 9F balloon catheters. Both injuries were on the right side and were approached through retroperitoneal incisions. Once proximal and distal control were obtained in these hypotensive patients, the right hypogastric artery was mobilized and spatulated end-to-end anastomoses performed with 6-O polypropylene interrupted sutures. Both children were doing well 1 year postoperatively with normal pulses and limb growth. The authors add this significant iatrogenic injury to a group of injuries that are the most common cause of arterial ischemia in infants and young children. They advise that prompt recognition and surgical correction are necessary to ensure normal limb growth and development.-Thomas F. Tracy. Jr
ALIMENTARY
TRACT
Long-Gap Esophageal Atresia: Experience With Reconstruction in 25 Patients. C. Festen, P.N.M.A. Rieu, F.H.J.M. van der Stuak, etaf. Eur J Pediatr Surg 1:139-141, (June), 1991. The authors report a series of 183 patients operated on for esophageal atresia in a ZO-year period, 25 of whom had a long-gap atresia that precluded immediate primary anastomosis. There were 11 boys and 14 girls. Multiple anomalies were diagnosed in 15 of the 2.5 infants. Eighteen patients were treated by proximal pouch stretching with the intention of doing a delayed primary anastomosis; five were treated by the Rehbein “thread technique”: and two patients underwent colonic interposition. The overall survival rate was 80%, which compares favorably with the results of esophageal replacement reported in the literature.-Thomas A. Angerpointner Congenital Esophagostenosis. R. Merger, M. Miiller, F. Sennhauser, ef al. Eur J Pediatr Surg 1:142-144, (June), 1991. The incidence of congenital esophagostenosis is 1 in 50,000 live births. Two patients with this very rare entity are reported. Clinical signs are frequent vomiting, regurgitation of undigested food without acid smell, and regurgitation of viscous mucus and saliva. Both patients underwent surgical repair. It is suggested that primary operation should replace bougienage treatment formerly in use.Thomas A. AngeTointner Esophageal pH Monitoring: Methodology, Indication and Interpretation. Y. Vundenplas. Eur J Pediatr Surg 1:67-72, (April), 1991. Gastroesophageal reflux (GER) may be considered as a cause of esophagitis, failure to thrive, and anemia. However, it is also recognized as a physiological phenomenon occurring especially in