Bert W. Meyer

Pleural Empyema in Children

n the late 1950’s a tremendous increase in the incidence of staphylococcal pneumonia and empyema occurred throughout many of the I pediatric centers in the country. This increase was thought to have been caused by the emergence of antibiotic-resistant strains of bacteria [3]. Several papers appeared in the literature reflecting this changing pattern [4, 6, 71, and some strict rules for surgical management were advised in order to decrease mortality in this disease [6]. Formerly, this mortality ranged from a high of 100% in some series [l] to about 25% in other centers [5, 61. The generally accepted surgical routine was to insert a chest tube in all children who exhibited pleural fluid containing gram-positive cocci. This was followed frequently by conversion to open drainage with or without rib resection, and finally decortication if there was no definite improvement in two or three weeks and a captive lung was assumed to be present. Strict adherence to these principles brought the mortality down to around 10 or 12% [6]. Since about 1962, pleural empyema in children, particularly that due to staphylococci, has become less virulent, probably entirely as the result of newer antibiotic agents. Now certain transgressions can be taken from the older rules of management in order to shorten the hospital stay and decrease the discomfort of these children. It is the purpose of this paper to review the experience with all children diagnosed as having primary pneumonia and secondary empyema over the past 20 years at the Children’s Hospital of Los Angeles, in order to compare present-day management with that practiced 10 years ago.

Foregut cysts in infants and children. Diagnosis and management.

The charts of 15 patients with foregut cysts were reviewed. The lesions were intrathoracic in 14 patients and in the cervical area in one child. The importance of early diagnosis and surgical management is stressed. In untreated infants with foregut cysts, severe progressive and life-threatening airway obstruction may develop. Since the symptoms of this congenital lesion may simulate other more common diseases of the tracheobronchial tree and esophagus, the physician should become familiar with this disease entity so that proper diagnosis and surgical treatment will not be delayed. The study includes symptomatology, methods of diagnosis, pathologic findings and classification of the cysts.

Cardiopulmonary arrest: Evaluation of an active resuscitation program☆

Abstract Cardiopulmonary resuscitation efforts in response to an emergency call are analyzed as to effectiveness in 302 patients. Over a seven year period there had been a marked improvement in the success rate of resuscitation. The reasons for this are the recognition of the patients most likely to suffer cardiac arrest and the monitoring of these patients closely in special units where nurses trained in resuscitation are constantly in attendance.

The Selection and Medical Management of Patients with Mitral Stenosis Treated by Mitral Commissurotomy

The selection of patients for mitral commissurotomy must be made after considering all manifestations of the rheumatic state. A conservative approach is urged and no patients should be operated upon without evidences of increasing pulmonary hypertension and right heart strain. The preparation of the patient, the management of the arrhythmias during surgery and the postoperative care are the full responsibilities of the physician. A team composed of physiologists, cardiologists and surgeons must work together.

Escherichia coli Endocarditis after Repair of Ventricular Septal Defects

Abstract Therapy of two children with ventricular septal defects who were successfully treated for postcardiotomy Escherichia coli endocarditis included ampicillin, kanamycin and reoperation, with removal of the patch in one child and removal of infected sutures in the other. An additional complication was an aneurysm of the right ventricle that was secondary to the infection and that required resection. This child had two additional ventriculotomies in addition to the original corrective surgery during the six and a half months in the hospital. This child also had a Candida albicans bloodstream infection that was successfully eradicated with amphotericin B. A review of the pertinent literature indicates that although the incidence of postcardiotomy endocarditis is relatively low at 0.1 to 2.7 per cent, the mortality varies from 40 to 100 per cent. A combined approach to therapy with appropriate antibiotics in resistant postcardiotomy endocarditis, followed by reoperation, with removal of foreign material...

Palliative Procedure for Treatment of Transposition of the Great Vessels

1. Extreme efforts at palliation seem indicated in the very young infant with transposition of the great vessels and no accompanying defects of note since good candidates for later total correction may thereby be preserved.[see table in the PDF file]2. A palliative procedure is presented wherein an atrial septal defect is created, and the blood flow from the inferior vena cava is diverted through the defect.3. Presented are nine patients less than two months of age and with arterial oxygen saturations less than 35% who underwent the described procedure.4. There were two early and two late deaths. The survivors are all doing well clinically and have required no further procedure.

The Surgical Repair of Endocardial Cushion Defects

he incidence of endocardial cushion defects in a surgical series is not high. In our series of more than 1,300 open-heart operations T for congenital cardiac defects, this anomaly has been encountered 39 times. The surgical repair of these defects is attended by a significant mortality rate-26% of 256 cases as reported by the Committee on Cardiovascular Surgery of the American College of Chest Physicians [Z]. The problems of persisting mitral valvular incompetence [ 1, 10, 171 and surgical heart block [Z, 6-81 continue to be a challenge to the cardiac surgeon, as does the quest for completely satisfactory operative techniques to repair the more severe forms of endocardial cushion defects. This report analyzes our experience with the 39 cases of endocardial cushion ,defects that we have operated upon.

Surgical Correction of Tetralogy of Fallot with Previous Systemic to Pulmonary Artery Shunts

Fifty-four patients with previous Blalock (32) and Potts (22) systemic artery-pulmonary artery shunts and subsequent total correction for tetralogy of Fallot are reported. A separate posterolateral approach was employed to obliterate the Potts shunt. There were seven operative deaths and two late deaths. Infundibular stenosis with a normal pulmonary valve gave the best results. In comparison with our concomitant series without a shunt, the presence of a Blalock or Potts anastomosis did not affect the over-all result. Postoperative bleeding was a major complication, requiring reoperation in seven. An excellent result with probable cure was obtained in 30, and there was good improvement in ten of the 54 patients.

A Method for Insertion of a Stented Xenograft Valve in the Atrioventricular Position

To facilitate the insertion of prosthetic valves, holders are available which keep the poppet out of the area of suture insertion or keep the open ends of the struts occluded. No such holders are available for use during insertion of xenograft valves, and it seems unlikely that one could be used, for danger of damage to the valve leaflets. To obviate this problem, we have brought the flexible struts together with a suture at the time of insertion. The struts assume their original open position upon cutting the suture.

How to Shorten, Lengthen, or Untwist Saphenous Vein Grafts

A simple method is described to correct saphenous vein bypass grafts that inadvertently have been made too long or too short or have become twisted. The essential feature of the technique is the use of a Satinsky vascular clamp to hold the divided ends of the vein and maintain their alignment during the repair. The most accessible portion of the vein is used as the site for the repair, leaving the aortic and coronary artery ends of the graft intact. While we have not had need to use the technique frequently, we have found it to be a simple method and believe it to be useful when such instances arise.