Arvin I. Philippart

Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment

Hemorrhage related to systemic heparinization is the major complication of extracorporeal membrane oxygenation (ECMO). Intracranial hemorrhage (ICH) is the most devastating complication. ICH developed in 13 of our 25 ECMO patients (52%). Six died, six survived with normal neurologic function, and one is severely impaired. In nine of 13 patients (69%) ECMO was discontinued when serial cranial ultrasounds showed progressive ICH. Seizures developed in six infants while receiving ECMO, and ICH developed in all. There is a correlation between hypertension and ICH. A hypertension index (hours systolic BP greater than 90/hours receiving ECMO) was 0.1 +/- 0.12 for infants without ICH and 0.37 +/- 0.28 for infants with ICH (P less than .05). ICH developed in 79% of the patients with an index greater than 0.1. Twenty neck explorations were required in the first 20 patients for incisional bleeding (mean blood loss, 21.9 +/- 18.0 mL/kg/d). We now use fibrin glue following cannulation and have done only one neck exploration in the last five patients (mean blood loss, 2.8 +/- 2.2 mL/kg/d, P less than .05). Endobronchial bleeding has responded to phenylephrine lavage and increased positive end-expiratory pressure. We have controlled pleural space bleeding with topical thrombin. None of the hemorrhagic complications encountered correlate with the activated clotting time or the amount of heparin used. There is an increased risk of hemorrhage associated with platelet counts less than 100,000/microL for 75% of a day (P less than .05) so that aggressive platelet transfusion remains important in preventing hemorrhagic complications during ECMO.

Pancreatitis in childhood: experience with 49 patients

Pancreatitis in children is not common but can be associated with severe morbidity rates. We have treated 49 children with pancreatitis over the past 12 years ranging in age from 1 month to 18 years. One third of the patients had biliary tract disease as an etiology, with nearly half of these being related to underlying hematologic disease, usually sickle cell anemia. Another third of the pancreatitis was due to trauma, and one third of these were related to child abuse. Other etologies were systemic disease (6 patients), congenital anomalies (8 patients), and idiopathic (3 cases). Eighty-two per cent of the patients presented with abdominal pain, but four children, all less than 4 years old, presented with an abdominal mass. Twenty-nine patients required 33 operations for pancreatitis. Fifteen of the 16 patients with biliary tract disease and all patients with congenital anomalies required operation. Six of the 16 patients with trauma required operation and none of those with systemic disease. As in adults ultrasonographic examination and CT scan are most important in the diagnosis; medical treatment consists of intravenous (I.V.) fluids, nasogastric suction, and total parenteral nutrition (TPN), and risk factors can help predict the severity of the disease while amylase alone is not related to severity. Different from adults, in children an etiology can usually be determined. The common etiologies, biliary tract disease, trauma, and congenital anomalies frequently require operation.

A new intratracheal stent for tracheobronchial reconstruction: Experimental and clinical studies

An intraluminal tracheal stent (ITS) was used experimentally in rabbits and piglets, as well as clinically in infants with tracheal stenosis, to facilitate airway reconstruction. The ITSs were constructed of stainless-steel springs covered with silicone rubber. They were implanted in seven piglets (6 to 8 kg), five rabbits (3 to 5 kg) and three infants. No animals developed severe respiratory distress and all appeared to tolerate the ITS. Postmortem examinations 1 to 8 weeks after surgery showed (1) loss of stent fixation (one pig), (2) increased tracheal secretions, (3) pneumonia (one pig, two rabbits), and (4) focal squamous metaplasia of tracheal mucosa. Stents used to treat three infants (2 to 5 months of age) with complex tracheobronchial stenosis were placed at the time of periosteal tracheoplasty in two. Recurrent stenosis necessitated a second tracheoplasty and stenting in one, and a long tracheostomy tube and balloon dilatations in the other. The third child had endoscopic stent insertion to alleviate severe airway collapse after esophageal tracheoplasty. The child died from progressive respiratory failure after stent dislodgment. Although the stents were well tolerated in animals and they enhanced critical ventilation of all pulmonary lobes in infants after tracheal reconstruction, certain modifications such as alternative methods of fixation, accommodation for tracheal growth, and reduction in tissue reactivity are necessary before further use of the ITS can be advocated.

Transpleural repair of esophageal atresia without a primary gastrostomy: 240 patients treated between 1951 and 1983

Esophageal atresia with distal tracheoesophageal fistula has been treated at one institution between 1951 and 1983 primarily by prompt transpleural repair without gastrostomy. Two hundred and seventy one patients are assigned to three time periods: (1) 1951 to 1963, prior to modern intensive care; (2) 1964 to 1973, the initial era of mechanical ventilation; and 1974 to 1983, the era of readily available ventilators and TPN. During these time periods mean birthweight decreased from 2,780 g to 2,670 g to 2,500 g, while the incidence of associated anomalies increased from 41% to 44% to 55%. Eleven patients had no operation or gastrostomy only and died. Twenty (predominantly in the early years) had staged repairs with initial gastrostomy and fistula ligation. Primary anastomosis was done in 240 patients regardless of birth weight, 229 of which were by the transpleural approach. Gastrostomy was performed primarily in 28 patients for varied indications. Operative mortality (definitive as well as staged repairs) fell over the three time periods from 44% to 15% to 7%. Anastomotic leaks occurred in 20% of patients who underwent primary repair regardless of the time period. The mortality associated with a leak, however, decreased from 88% to 47% to 0%. Anastomotic strictures requiring more than two dilatations occurred in 15% in all periods. The overall incidence of recurrent fistula was 5%. Of 200 patients surviving the initial hospitalization, follow-up longer than 2 months is available for 156 patients with a median follow-up of 30 months. There were 15 late deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal small left colon syndrome : Intramural not intraluminal obstruction

We have described a characteristic syndrome of intestinal dysfunction in infants of diabetic mothers. This finding appears to result from a transient intramural dysfunction. Many respond to rectal irrigations alone. However, a significant number will require close observation and possible diversion for persistent partial intestinal obstruction. Failure to recognize persistent obstruction may result in intestinal perforation.

Congenital Tracheal Anomalies in the Craniosynostosis Syndromes

The authors present the case of a 12-year-old girl with Pfeiffers syndrome who underwent successful resection of a tracheal cartilaginous sleeve (TCS) for treatment of sleep apnea. There is growing recognition of the inclusion of TCS in the spectrum of congenital cartilage malformations seen in patients with craniosynostosis (CS) syndromes. This case demonstrates the difficult therapeutic challenge created by the combination of hypopharyngeal and intrinsic airway abnormalities present in CS patients. The early recognition of TCS in these patients may provide the opportunity for improved outcome in this severely affected subgroup of CS patients with otherwise high mortality.

Preoperative exchange transfusion in sickle cell anemia

Preoperative transfusion therapy is largely responsible for the recently improved morbidity and mortality in patients with sickle cell anemia undergoing surgery. The transfusion techniques recommended are several. Fifty patients have undergone 67 operations over the past 15 yr. The complications encountered in patients receiving simple transfusion or partial exchange transfusion do not differ. There remains theoretic advantage in the use of preoperative partial exchange transfusion with quantitation of hemoglobin S.

Cystic adenomatoid dysplasia of the lung

Cystic adenomatoid dysplasia of the lung is an unusual lesion, only 142 cases having been reported in the English literature by 1979. This review describes 32 additional previously unreported patients treated at our institution. The male:female ratio was 1.4:1 and lesions were equally distributed in both lungs. The age range at presentation was 1 day-14 yr. This large experience identifies two distinct modes of presentation. Ten patients presented as newborns with acute progressive respiratory distress secondary to mediastinal displacement and pulmonary compression as a result of the expanding cystic lesion. This group of patients ranged from 1 to 28 days with a mean of 9.4 days of age. Of the remaining patients, varying from 2 mo to 14 yr, half were under 1 yr. The presentation in this group was generally different. Unresolving pulmonary infiltrate (5) or recurrent respiratory infection localized to the same portion of the lung (7) prompted the diagnosis of a pulmonary developmental abnormality. Three children in this group had failure to thrive. Progressive dyspnea was not a characteristic finding. Specific lobar or segmental resection effectively eradicated the disease process. All of the last 30 patients resected have survived without unusual sequelae. Cystic adenomatoid dysplasia should be considered in the differential diagnosis of progressive respiratory disease in the neonate or of recurrent or persistent pneumonic processes in the same segment of the lung in the older child.

The treatment of retained peripheral foreign bodies in the pediatric airway

Aspiration of foreign bodies into the pediatric airway is a common surgical emergency condition. Once impacted into the peripheral airway, repeated attempts at removal may push these objects into segmental bronchi, causing endobronchial bleeding, and prolonged anesthesia time. In addition to standard endoscopic techniques, the use of fluoroscopy, endobronchial contrast material, topical vasoactive medications, and diverse retrieval instruments in eight such cases has avoided the need for either bronchotomy or segmental pulmonary resection. By using such supportive intraoperative techniques, the morbidity and mortality from impacted airway foreign bodies can be greatly reduced.

Balloon dilatation of postoperative tracheal stenosis.

Three patients who had previously undergone linear augmentation tracheoplasty developed postoperative stenosis within the grafted segment. In each patient, balloon catheter dilatation successfully enlarged the stenotic airway obviating secondary reconstruction in two.