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Traumatic rupture of the thoracic aorta in childhood with special reference to the therapeutic strategy
INTERNATIONAL
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ABSTRACTS
nal collections related to spinal injury, and two mediastinal fluid collections were of unknown origin. Four children had incidental findings, including ill-defined right apical opacity of the azygous lobe fissure, widening of the mediastinum on chest x-ray which was found to be a normally located right aortic arch on CT, tortuous aorta in a child with Marfan’s syndrome, and a large partially calcified paravertebral benign ganglioneuroma in another child. Although this is a retrospective study, the authors conclude that CT scan can demonstrate the true extent of the underlying injury which may be useful in subsequent management as the child’s compliant thoracic cage may not sustain fractures which in adults serve as clues to the severity of the blunt chest trauma.-P. Puri
went nonanatomic pulmonary resections. In these lesions, the normal surface landmarks of the pulmonary lobes were absent. Due to the bulk of the lesions, large thoracotomy incisions were used for exposure. Dissection of the hilar areas was done to identify the main bronchi and pulmonary arteries. A nonanatomic resection was begun by entering the lesion 1 cm inferior to its interface with intact pulmonary remnants. Areas of air leak or bleeding were controlled by pledgeted suture. Stapling devices were not used, nor were any other augmentation procedures utilized. All patients survived with proportional lung growth and development. The authors conclude that because of this potential for expansion and growth, nonanatomic resection will permit preservation of these remnants at an acceptable level of risk.-Thomas
Traumatic Rupture of the Thoracic Aorta in Childhood With Special Reference to the Therapeutic Strategy. H. Str$j%ler, F. Leupi, G. Kaiser, et al. Eur J Pediatr Surg 3:50-53, (February), 1993.
F. Tracy, Jr
Acute traumatic tear of the aorta is extremely rare in childhood. Based on their experience with two children, the authors discuss the essential diagnostic and therapeutic measures with special reference to timing of surgery. Aortic disruption must be suspected in a child who sustains severe blunt chest injury and develops an abnormally wide mediastinum. Definite diagnosis is established by aortography and CT scan. The appropriate therapeutic approach is determined by clinical symptoms and particularly by the severety of concomitant lesions. In the absence of a significant hemothorax and if no difference in pulse amplitude between upper and lower extremities is evident, the risk of free aortic rupture with intrathoracic exsanguination is presumed to be rather low if the patient reaches the hospital alive. In that situation, the continuity of the injured aorta is maintained by the adventitia and surrounding mediastinal structures. Therefore, these patients may derive the benefit from an initially conservative management including pharmacological intervention to reduce the risk of free aortic rupture. This concept is particularly indicated when aortic disruption is associated with severe concomitant injury, such as intraabdominal or intracranial lesions. Such injuries preclude safe aortic repair immediately after establishment of diagnosis. Delay of aortic repair until recovery from associated major injury allows heparinization and the use of a pump oxygenator, which is regarded as the most effective method to prevent spinal cord ischemia and to reduce the risk of paraplegia.-Thomas A. Angelpointner Coexistence of Bronchial Atresia and Bronchogenic Cyst: Diagnostic Criteria and Embryologic Considerations. C. Kuhn andJ.P. Kuhn. Pediatr Radio1 22:568-570, (December), 1992.
The authors report a male newborn with a bronchogenic cyst and bronchial atresia that were accurately diagnosed preoperatively by ultrafast computed tomography. Bronchogenic cysts occur by separation and arrest in the development of local portions of the tracheobronchial trees from the adjacent airways during the branching stage at about the 5th week of fetal life. The authors, support the theory that an insult in the 5th week of intrauterine life may result in both these conditions. An alternative theory suggests that the presence of a bronchogenic cyst may predispose the patient to subsequent bronchial atresia.--R. Suruna The Use of “Nonanatomic” Pulmonary Resection in Infants With Extensive Congenital Adenomatoid Malformation of the Lung. D. Browdie, D. Todd, R. Agnew, et al. J Thorac Cardio-
vast Surg 105:732-736, (April), 1993. In the majority of patients with cystic adenomatoid malformation, lobectomy has been the treatment of choice. With more extensive malformations of the lung, pneumonectomy has been suggested. This study documents the course of three infants with congenital cystic adenomatoid malformation (CCAM), who under-
Lung Volumes, Mechanics, and Perfusion After Pulmonary Resection in Infancy. H.A. Werner, G.E. Pirie, H.R. Nadel, et al. J
Thorac Cardiovasc Surg 105:737-742, (April), 1993. To examine the lungvolumes, mechanics, and perfusion in infants after pulmonary resection. the authors studied 14 patients, at ages 3 to 20 years after they had undergone partial pulmonary resection at ages ranging from 1 week to 30 months. Predicted pulmonary function values accounted for the relative amount of lung removed and were reported as “predicted-corrected values.” Overall, there were no abnormalities found in physical development. The majority of children had abnormal regional ventilation but normal equilibration. Five patients had gas retention; 9 patients showed ventilation perfusion mismatch. Lung volumes were within the predicted range in 12 patients. However, the residual volume and functional residual capacity were larger than the predicted corrected values in most patients. Residual volume in relation to total lung capacity was at or below normal in 6 patients. The authors conclude that lung resection in early childhood leads to good functional recovery despite decreased expiratory flows, regional ventilation abnormalities, and decreased perfusion.--Thomas F. Tracy, Jr Pediatric Lung Transplantation: The Years 1985 to 1992 and the Clinical Trial of FK 506. J. Armitage, G. Kurland, M. Michaels, PIal. J Thorac Cardiovasc Surg 105:337-346, (February), 1993.
The authors review 20 pediatric patients (aged 13 to 18 years) who had undergone lung transplantation for pulmonary hypertension (7) congenital heart disease (5) cystic fibrosis (4), pulmonary arteriovenous malformation (2) graft-versus-host disease (l), and desquamative interstitial pneumonitis (1). Twenty percent of these patients had thoracic surgical procedures before transplantation. Survival was 80% with a mean follow-up of 2 years for heart lung (n = 11). double-lung (n = S), and single lung (n = 1) transplants. The mean number of rejection episodes was 1.4 at 30 days, 0.5 at 30 to 90 days, and 1.4 at greater than 90 days. Obliterative bronchiolitis developed in 16 patients who survived more than 100 days: however, pulmonary function tests remained good in almost all recipients. Eleven patients in this group received FK 506 as the basis of their immunosuppressive protocol. In thisvery preliminary, nonrandomized study there were no statistically significant difference in complications or rejection between patients treated with cyclosporine and those with FK 506. However, no patient in the FK SO6 group required treatment with any antilymphocyte agent for rejection.-Thomas F. Tracy, Jr Experience With Delayed Repair of Congenital Diaphragmatic Hernia During Extracorporeal Membrane Oxygenation in a European Centre. F. vd. Staak, W. Geven, B. Oeseburg, et al.
Pediatr Surg Int 8:187-190, (April), 1993. The authors present their experience with extracorporeal membrane oxygenation (ECMO) in 6 of 14 high-risk patients with
1510
ABSTRACTS
nal collections related to spinal injury, and two mediastinal fluid collections were of unknown origin. Four children had incidental findings, including ill-defined right apical opacity of the azygous lobe fissure, widening of the mediastinum on chest x-ray which was found to be a normally located right aortic arch on CT, tortuous aorta in a child with Marfan’s syndrome, and a large partially calcified paravertebral benign ganglioneuroma in another child. Although this is a retrospective study, the authors conclude that CT scan can demonstrate the true extent of the underlying injury which may be useful in subsequent management as the child’s compliant thoracic cage may not sustain fractures which in adults serve as clues to the severity of the blunt chest trauma.-P. Puri
went nonanatomic pulmonary resections. In these lesions, the normal surface landmarks of the pulmonary lobes were absent. Due to the bulk of the lesions, large thoracotomy incisions were used for exposure. Dissection of the hilar areas was done to identify the main bronchi and pulmonary arteries. A nonanatomic resection was begun by entering the lesion 1 cm inferior to its interface with intact pulmonary remnants. Areas of air leak or bleeding were controlled by pledgeted suture. Stapling devices were not used, nor were any other augmentation procedures utilized. All patients survived with proportional lung growth and development. The authors conclude that because of this potential for expansion and growth, nonanatomic resection will permit preservation of these remnants at an acceptable level of risk.-Thomas
Traumatic Rupture of the Thoracic Aorta in Childhood With Special Reference to the Therapeutic Strategy. H. Str$j%ler, F. Leupi, G. Kaiser, et al. Eur J Pediatr Surg 3:50-53, (February), 1993.
F. Tracy, Jr
Acute traumatic tear of the aorta is extremely rare in childhood. Based on their experience with two children, the authors discuss the essential diagnostic and therapeutic measures with special reference to timing of surgery. Aortic disruption must be suspected in a child who sustains severe blunt chest injury and develops an abnormally wide mediastinum. Definite diagnosis is established by aortography and CT scan. The appropriate therapeutic approach is determined by clinical symptoms and particularly by the severety of concomitant lesions. In the absence of a significant hemothorax and if no difference in pulse amplitude between upper and lower extremities is evident, the risk of free aortic rupture with intrathoracic exsanguination is presumed to be rather low if the patient reaches the hospital alive. In that situation, the continuity of the injured aorta is maintained by the adventitia and surrounding mediastinal structures. Therefore, these patients may derive the benefit from an initially conservative management including pharmacological intervention to reduce the risk of free aortic rupture. This concept is particularly indicated when aortic disruption is associated with severe concomitant injury, such as intraabdominal or intracranial lesions. Such injuries preclude safe aortic repair immediately after establishment of diagnosis. Delay of aortic repair until recovery from associated major injury allows heparinization and the use of a pump oxygenator, which is regarded as the most effective method to prevent spinal cord ischemia and to reduce the risk of paraplegia.-Thomas A. Angelpointner Coexistence of Bronchial Atresia and Bronchogenic Cyst: Diagnostic Criteria and Embryologic Considerations. C. Kuhn andJ.P. Kuhn. Pediatr Radio1 22:568-570, (December), 1992.
The authors report a male newborn with a bronchogenic cyst and bronchial atresia that were accurately diagnosed preoperatively by ultrafast computed tomography. Bronchogenic cysts occur by separation and arrest in the development of local portions of the tracheobronchial trees from the adjacent airways during the branching stage at about the 5th week of fetal life. The authors, support the theory that an insult in the 5th week of intrauterine life may result in both these conditions. An alternative theory suggests that the presence of a bronchogenic cyst may predispose the patient to subsequent bronchial atresia.--R. Suruna The Use of “Nonanatomic” Pulmonary Resection in Infants With Extensive Congenital Adenomatoid Malformation of the Lung. D. Browdie, D. Todd, R. Agnew, et al. J Thorac Cardio-
vast Surg 105:732-736, (April), 1993. In the majority of patients with cystic adenomatoid malformation, lobectomy has been the treatment of choice. With more extensive malformations of the lung, pneumonectomy has been suggested. This study documents the course of three infants with congenital cystic adenomatoid malformation (CCAM), who under-
Lung Volumes, Mechanics, and Perfusion After Pulmonary Resection in Infancy. H.A. Werner, G.E. Pirie, H.R. Nadel, et al. J
Thorac Cardiovasc Surg 105:737-742, (April), 1993. To examine the lungvolumes, mechanics, and perfusion in infants after pulmonary resection. the authors studied 14 patients, at ages 3 to 20 years after they had undergone partial pulmonary resection at ages ranging from 1 week to 30 months. Predicted pulmonary function values accounted for the relative amount of lung removed and were reported as “predicted-corrected values.” Overall, there were no abnormalities found in physical development. The majority of children had abnormal regional ventilation but normal equilibration. Five patients had gas retention; 9 patients showed ventilation perfusion mismatch. Lung volumes were within the predicted range in 12 patients. However, the residual volume and functional residual capacity were larger than the predicted corrected values in most patients. Residual volume in relation to total lung capacity was at or below normal in 6 patients. The authors conclude that lung resection in early childhood leads to good functional recovery despite decreased expiratory flows, regional ventilation abnormalities, and decreased perfusion.--Thomas F. Tracy, Jr Pediatric Lung Transplantation: The Years 1985 to 1992 and the Clinical Trial of FK 506. J. Armitage, G. Kurland, M. Michaels, PIal. J Thorac Cardiovasc Surg 105:337-346, (February), 1993.
The authors review 20 pediatric patients (aged 13 to 18 years) who had undergone lung transplantation for pulmonary hypertension (7) congenital heart disease (5) cystic fibrosis (4), pulmonary arteriovenous malformation (2) graft-versus-host disease (l), and desquamative interstitial pneumonitis (1). Twenty percent of these patients had thoracic surgical procedures before transplantation. Survival was 80% with a mean follow-up of 2 years for heart lung (n = 11). double-lung (n = S), and single lung (n = 1) transplants. The mean number of rejection episodes was 1.4 at 30 days, 0.5 at 30 to 90 days, and 1.4 at greater than 90 days. Obliterative bronchiolitis developed in 16 patients who survived more than 100 days: however, pulmonary function tests remained good in almost all recipients. Eleven patients in this group received FK 506 as the basis of their immunosuppressive protocol. In thisvery preliminary, nonrandomized study there were no statistically significant difference in complications or rejection between patients treated with cyclosporine and those with FK 506. However, no patient in the FK SO6 group required treatment with any antilymphocyte agent for rejection.-Thomas F. Tracy, Jr Experience With Delayed Repair of Congenital Diaphragmatic Hernia During Extracorporeal Membrane Oxygenation in a European Centre. F. vd. Staak, W. Geven, B. Oeseburg, et al.
Pediatr Surg Int 8:187-190, (April), 1993. The authors present their experience with extracorporeal membrane oxygenation (ECMO) in 6 of 14 high-risk patients with