Bradley M. Rodgers

Thoracoscopy in children.

In the past four and one-half years we have used thoracoscopy as the primary technique for pulmonary biopsy in children. During that interval, over 80 thoracoscopic procedures have been performed with no mortality and minimal morbidity. The ages of the patients have ranged between 2 weeks and 20 years. The procedure is carried out in the general operating room under regional and intravenous anesthesia, avoiding the need for endotracheal intubation. Fourty-two of the procedures have been performed in immunosuppressed patients, attempting to determine the presence of Pneumocystis carinii pneumonia. Twenty-four of the procedures have been performed for the diagnosis of intrathoracic tumors while 15 procedures have been performed for the diagnosis of localized pulmonary infiltrates. The diagnostic accuracy in immunosuppressed patients has been 100 persons and in the tumor patients has been 92 percent. The complications of this technique have been minimal. Four patients developed pneumothoraces which responded to manipulation of the chest tube and 3 patients have had sufficient postoperatoire bleeding to require transfusion, while none have required re-exploration. The technique of thoracoscopy has provided a safe and rapid method of pulmonary diagnosis in this aged patient.

Patient-controlled analgesia in pediatric surgery

Patient-controlled analgesia (PCA) with a microprocessor-operated infusion syringe was first suggested for human use in 1965. Clinical studies from the United States and Europe have shown this form of analgesia to be well accepted by adults, but the use of this technology for children has not been studied. We evaluated PCA in 15 consecutive pediatric surgical patients between the ages of 11 and 18 years undergoing major thoracic or abdominal surgery. The patients and their parents were instructed in the use of the equipment prior to surgery and PCA was initiated after the patients left the recovery room. The mean duration of PCA was 2.6 days. No serious mechanical difficulties with the infusion apparatus were encountered. The acceptance of PCA was excellent with only two patients preferring some other method of analgesia. Pain relief was assessed twice daily by a registered nurse using a verbal-visual pain scale. On a 1 to 10 scale average pain relief was 7.2. Eight of the patients had had a previous operation, and seven of these reported that PCA was a better method of achieving pain control. A comparison of the 15 study patients with 15 previous patients with similar procedures indicated that PCA patients used less analgesia in the postoperative period, although they tended to use more in the first 24 hours. PCA is found to be a safe and effective means of analgesia in pediatric patients. Adequate pain relief was achieved with less analgesia and with less nursing attention. This technology is recommended for postoperative pediatric patients.

Pleuroperitoneal shunts in the management of neonatal chylothorax

Pleuroperitoneal shunts have been placed in five ventilator-dependent newborns with persistent chylothorax. The etiology of the chylothorax appeared to be secondary to superior vena caval obstruction in three patients and was idiopathic in the remaining two. Despite traditional therapies these infants were on a progressively deteriorating clinical course. Hakim-Cordis low-pressure ventricular-peritoneal shunt catheter systems were used in each infant. Ultrasonography was used to follow the regression of pleural effusions and to determine the need for shunt compression. Shunt patency was confirmed with radionuclide studies. Four of five infants had a complete resolution of their chylothorax and pulmonary insufficiency. Three of these infants were extubated within 28 days following the placement of the shunt. Nutritional and metabolic stability was rapidly achieved. The shunts were removed several weeks later without recurrence of the chylothorax. A fifth infant failed to improve after the placement of the pleuroperitoneal shunt and died of progressive pulmonary insufficiency. The placement of pleuroperitoneal shunts in infants with refractory chylothorax is safe, technically easy to perform, and is associated with few complications.

Thoracoscopy for intrathoracic neoplasia in children

The technique of thoracoscopy allows a unique opportunity to examine the entire hemithorax. Between July 1975 and April 1981 we performed over 150 thoracoscopic procedures for evaluation of intrathoracic pathology at the University of Florida. Twenty-five of these procedures, performed in 23 patients, were undertaken for the diagnosis or staging of intrathoracic tumors in patients whose ages ranged from 8 mo to 18 yr. Forty-eight percent were for parenchymal tumors, 44% for mediastinal masses, and 8% for pleural disease. Twelve of these patients had at least 1 invasive procedure performed prior to thoracoscopy without a diagnosis being established. In 17 procedures a positive tissue diagnosis of malignancy was obtained, and in 6 of these cases areas of previously unsuspected intrathoracic tumor involvement were identified by thoracoscopy. In 3 patients simultaneous thoracoscopy-guided transdiaphragmatic needle biopsy of the liver was performed with a positive tumor diagnosis being achieved in 1. The clinical course of the patients following the 8 procedures in which neoplasia was not encountered confirmed the diagnosis of benign disease in all but 1. A single patient with an enlarged mediastinal lymph node had a falsely negative thoracoscopy biopsy and was subsequently diagnosed as having recurrent Hodgkins disease. The overall diagnostic accuracy in these patients was, therefore, 92%. Complications in these patients have been minimal, and there was not mortality due to the thoracoscopic procedure. These clinical results would suggest an important role for thoracoscopy in the evaluation of intrathoracic neoplasia in children.

The use of preserved human dura for closure of abdominal wall and diaphragmatic defects.

The surgical management of large body wall defects presents special challenges. The prosthetic materials employed for these defects, although readily available, have the disadvantage of susceptibility to infection. Autologous tissue is frequently not available in sufficient quantity. The long-term functional and histologic results of the use of preserved human dura for closure of abdominal wall and diaphragmatic defects have been evaluated. Dural patches were sutured into abdominal wall and diaphragmatic defects of six dogs, using interrupted sutures of Dexon and Prolene. The animals were killed eight, 16 and 24 weeks after patch placement. The strength of the material was tested with a pneumoperitoneum prior to death and in all animals it appeared firmly incorporated into the host tissue. Histologically there was a mononuclear inflammatory response seen at eight weeks, with resolution by 24 weeks. Ingrowth of surrounding collagen and muscular tissue produced a firm union between the homologous material and the host tissue. The results of this study indicate that preserved human dura is an excellent material for closure of body wall defects. It appears to be well tolerated by host tissue and maintains its strength over prolonged periods of time.

Talc poudrage in the treatment of spontaneous pneumothoraces in patients with cystic fibrosis

As patients with cystic fibrosis live longer, spontaneous pneumothoraces are seen with increasing frequency. Severe underlying pulmonary disease in these patients makes them particularly susceptible to life-threatening respiratory distress. Several modalities, including chemical sclerosis and open thoracotomy with pleurectomy, have been used to treat pneumothoraces in these patients. In the past 4 years, pneumothoraces in five patients (ages 9-22 years) with cystic fibrosis have been treated with thoracoscopy and talc poudrage. All procedures were performed under either regional or general anesthesia, depending on the age of the patient. Thoracoscopy was performed with a rod lens system and a 5.5-mm trocar, using biopsy forceps to lyse pleural adhesions, all of which ensures access to the entire pleural surface. United States Pharmacopeia-certified talc was insufflated to cover the entire pleural surface. There were no complications, and the patients had minimal pleural pain. Follow-up ranged from 6 months to 4 years. No patient has had a recurrent pneumothorax on the treated side. Thoracoscopy with talc poudrage is a preferable alternative to chemical sclerosis or thoracotomy for treating pneumothoraces in patients with cystic fibrosis. The procedure may be performed under regional anesthesia and allows rapid and complete sclerosis of the pleural cavity.

Thoracoscopic Surgery for Diseases of the Lung and Pleura Effectiveness, Changing Indications, and Limitations

OBJECTIVEnThis study compared the results of video-assisted thoracic surgery (VATS) with thoracoscopic surgery (TS) for diseases of the lung and pleura.nnnSUMMARY BACKGROUND DATAnNo studies exist that compare the capabilities of VATS with advanced video systems and instrumentation to that of TS which has been done for 80 years.nnnMETHODSnA retrospective study was done comparing the effectiveness, indications, complications, and limitations of TS and VATS done for four categories of pleural disease: 1) pleural fluid problems, 2) diffuse lung disease, 3) lung masses, and 4) pneumothorax. The TS period was 1981-1990. The VATS period was 1991-1992.nnnRESULTSnEighty-nine consecutive TS cases and 64 consecutive VATS cases were reviewed. TS for resolution of pleural fluid problem was successful in 29 of 34 patients (85%), and VATS was successful in 18 of 20 (90%). Diffuse lung disease was diagnosed by TS using a cup biopsy on end-stage patients in respiratory failure. Since 1991 the diagnosis has been made with VATS using stapled wedge excisions on ambulatory patients. Surgical mortality decreased from 33% (10 of 30) to 9% (1 of 11) and the postoperative stay from 16.6 +/- 2.4 days to 8.2 +/- 2.2 days. Lung masses were diagnosed entirely by incisional biopsies using TS. Diagnosis was made in 83% and postoperative stay was 5.3 +/- 1.0 day. VATS allowed excisional biopsies permitting diagnosis in 100% with a postoperative stay of 3.0 +/- 0.2 days (p = 0.05). However, 20% required conversion to thoracotomy to locate the subpleural mass. TS was performed for spontaneous pneumothorax in only 26% (5 of 19) of the total pneumothorax cases, whereas, VATS was used for spontaneous pneumothorax in 67% (12 of 18).nnnCONCLUSIONnVATS has continued the effectiveness of TS for treating pleural fluid problems, has resulted in earlier surgical diagnostic intervention in diffuse lung disease and earlier therapeutic intervention in primary pneumothorax states, and has markedly expanded the safety, efficacy and indications for lung mass biopsy.

Clinical application of endotracheal cryotherapy.

A nitrous oxide cryoprobe has been developed that may be used through the infant bronchoscope. A total of 19 discrete airway lesions have been treated in 17 patients ranging in age from 2 mo to 30 yr. Three patients with periglottic lesions have had complete eradication of these lesions without the need for tracheostomy. Six patients with subglottic stenoses have been treated, with one successful extubation and one patient approaching extubation. Five patients have been treated for distal tracheal strictures, with two successful extubations and a third pending extubation. Five patients have been treated for endotracheal granulation tissue, and 3 patients have been successfully extubated. Cryotherapy allows bloodless resection of these lesions with rapid tissue healing not accompanied by residual scarring.

Pediatric tracheostomy: Long-term evaluation

Considerable debate exists in the literature concerning the immediate and long-term risks of tracheostomy in the pediatric age group. Much has been written of the hazards of decannulation in these patients. A review of the experience of tracheostomy in patients under 18 yr of age at the Shands Teaching Hospital was undertaken. One hundred and eight children underwent tracheostomy between January, 1967, and August, 1976. There were 74 males and 34 females. Twenty-eight patients (27%) were less than 30 days of age at the time of tracheostomy and 68 (63%) were less than 1 yr of age. The indications for tracheostomy were varied, but 73 were performed because of mechanical airway obstruction or respiratory insufficiency. The vast majority (106) were performed on an elective basis and most of the cannulas employed were either silastic or polyvinyl chloride (88). Complications of tracheostomy were minor with 11 instances of pneumomediastinum or pneumothorax. Two patients have developed secondary tracheal stenosis that may have been caused by the tracheostomy. The overall mortality was 44% with 7 patients succumbing from complications of the tracheostomy itself. Four of these were in homemanaged patients. Forty-four of 49 patients considered candidates for decannulation have been successfully extubated. Tracheostomy in the pediatric age group appears to be well-tolerated as long as meticulous care is taken in the performance of the procedure and in follow-up. Decannulation has not been a significant problem in our series.

Bilateral congenital eventration of the diaphragms: Successful surgical management

Bilateral congenital eventration of the diaphragms is a relatively rare occurrence, associated with an almost uniform mortality. We recently have had experience with three patients who underwent successful treatment of this anomaly. Each patient presented as a newborn with severe respiratory insufficiency. One had had a sibling who died shortly after birth with a congenital diaphragmatic hernia. One infant had associated respiratory distress syndrome. PA and lateral chest roentgenograms demonstrated the anomaly in each patient. In two, the use of ultrasound clearly demonstrated the presence of attenuated diaphragms and paradoxical motion. Each infant underwent transabdominal bilateral diaphragmatic plication, reinforced with transversus abdominis muscle, within the first 2 weeks of life. Two infants showed prompt improvement in arterial blood gases and were extubated following the operation. The infant with respiratory distress syndrome required a tracheostomy for continued mechanical ventilation. This infant developed a recurrent eventration of the left diaphragm 6 months after the initial operation and has undergone a secondary plication with clinical improvement. Unlike unilateral eventration, bilateral eventration of the diaphragms is associated with persistent and significant respiratory symptoms. Surgical plication should be performed urgently in all of these patients, before chronic pulmonary changes occur.