Eugene D. McGahren

Use of video-assisted thoracic surgery in the treatment of chylothorax.

Chylothorax, a potentially lethal disorder that may cause profound respiratory, nutritional, and immunologic complications, has become increasingly common in recent years. Medical therapy has been found to have a significant failure rate. Therefore, surgical treatment of complicated chylothorax has become a mainstay of care. Between 1987 and 1993, ten patients at the University of Virginia Hospital were treated with video-assisted thoracic surgery for complicated chylothorax. Twelve thoracoscopic procedures were performed. Patients ranged in age from 7 months to 82 years. Causes included iatrogenic (2), congenital (2), caval thrombosis (2), amyloid (2), blunt trauma (1), and metastatic carcinoid tumor (1). In 10 cases, video-assisted thoracic surgery was employed as the principal mode of therapy: 8 using talc pleurodesis alone, 1 using talc pleurodesis and clipping of the thoracic duct with application of fibrin glue, and 1 requiring clipping of a pleural defect with application of fibrin glue. In 2 cases, a video-assisted thoracic operation was used in conjunction with pleuroperitoneal shunting: a previously placed pleuroperitoneal shunt that was malfunctioning was repositioned thoracoscopically after a pleural adhesiolysis, and a pleural adhesiolysis was performed thoracoscopically before placement of a pleuroperitoneal shunt. In all cases the effusion resolved after the video-assisted thoracic operation without further intervention. Video-assisted thoracic surgery offers an effective means of treating chylothorax, regardless of cause, allowing the advantage of access to thoracic structures without the morbidity of more extensive procedures.

Neurological outcome is diminished in survivors of congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation

In a series of 61 infants who had congenital diaphragmatic hernia (CDH) treated at our center from 1978 through 1996, 37 of 59 (61%) survived the perioperative period with two infants lost to follow-up. Nine (47%) of 19 infants survived before the introduction of extracorporeal membrane oxygenation (ECMO) into our region in 1986. Since 1986, 28 (70%) of 40 infants survived. Eighteen infants required ECMO, and 12 (75%) survived. A chart review was performed to determine whether infants surviving CDH are suffering from delays in neurological development, and, if so, whether this is attributable to ECMO. Of 12 ECMO survivors, 8 (67%) exhibited functional or anatomic evidence for neurological delay. Of 21 non-ECMO survivors, where adequate follow-up was available to make an assessment of neurological development, five (24%) exhibited evidence for delay. This difference was significant (P < .05, Fishers Exact test). Of these five infants, three were premature, and one had DiGeorge syndrome. More ECMO survivors required diaphragmatic (67%) and abdominal (67%) patches at the time of diaphragmatic repair than non-ECMO survivors (4% and 12%, respectively; P < .05, Fishers Exact test). In addition, more ECMO survivors required gastrostomy tube placement for feeding (50%) than non-ECMO survivors (16%; P < .05, Fishers Exact test). A greater need for Nissen fundoplication in ECMO survivors (42%) than in non-ECMO survivors (12%) approached significance (P = .05, Fishers Exact test). There were trends toward higher 1 and 5 minute APGAR scores and initial and best preoperative P(O2) in the non-ECMO survivors. A comparison between ECMO survivors who exhibited evidence of neurological delay with those who did not showed no differences in duration of ECMO, incidence of intracranial complications during ECMO, need for gastrostomy tube feeding or Nissen fundoplication, or incidence of carotid artery repair between the two groups. Infants surviving CDH who require ECMO have a greater incidence of neurological delay than those who do not. This is likely because of severity of the presenting illness as reflected by a greater need for diaphragmatic and abdominal patches during diaphragmatic repair, the need for Nissen fundoplication and gastrostomy tube feeding, and a trend toward poor APGAR scores and best preoperative P(O2) levels in these patients. However, there may be characteristics of ECMO, as yet unidentified, that may contribute to this outcome.

The effect of race and gender on pediatric surgical outcomes within the United States.

PURPOSE The purpose of this study was to examine risk-adjusted associations between race and gender on postoperative morbidity, mortality, and resource utilization in pediatric surgical patients within the United States. METHODS 101,083 pediatric surgical patients were evaluated using the U.S. national KID Inpatient Database (2003 and 2006): appendectomy (81.2%), pyloromyotomy (9.8%), intussusception (6.2%), decortication (1.9%), congenital diaphragmatic hernia repair (0.7%), and colonic resection for Hirschsprungs disease (0.2%). Patients were stratified according to gender (male: 63.1%, n=63,783) and race: white (n=58,711), Hispanic (n=26,118), black (n=9,103), Asian (n=1,582), Native American (n=474), and other (n=5,096). Multivariable logistic regression modeling was utilized to evaluate risk-adjusted associations between race, gender, and outcomes. RESULTS After risk adjustment, race was independently associated with in-hospital death (p=0.02), with an increased risk for black children. Gender was not associated with mortality (p=0.77). Postoperative morbidity was significantly associated with gender (p<0.001) and race (p=0.01). Gender (p=0.003) and race (p<0.001) were further associated with increased hospital length of stay. Importantly, these results were dependent on operation type. CONCLUSION Race and gender significantly affect postoperative outcomes following pediatric surgery. Black patients are at disproportionate risk for postoperative mortality, while black and Hispanic patients have increased morbidity and hospital resource utilization. While gender does not affect mortality, gender is a determinant of both postoperative morbidity and increased resource utilization.

Anesthetic techniques for pediatric thoracoscopy

BACKGROUND Since 1981, we have performed 68 thoracoscopic procedures in 62 patients aged 7 months to 21 years. METHODS We reviewed the anesthetic and ventilation strategy used for each procedure to determine which anesthetic strategies are safe and effective for particular children and conditions. RESULTS Regional anesthesia with sedation was used for six procedures in 5 patients with a mean age of 16 years (range, 9 to 21 years). One patient required conversion to general anesthesia. General anesthesia with one-lung ventilation was attempted for 18 procedures in 17 patients with a mean age of 12 years (range, 7 months to 18 years). Two patients required conversion to two-lung anesthesia secondary to pulmonary intolerance. One of these patients and 2 others required thoracotomy. General anesthesia with two-lung ventilation was used for 44 procedures in 41 patients with a mean age of 9 years (range, 1 to 17 years). There were no anesthesia-related difficulties. CONCLUSIONS Regional anesthesia should be limited to the older, more cooperative patient. General anesthesia with one-lung ventilation is useful in adolescents, as they tolerate collapse of one lung well, and it is particularly desirable for procedures requiring exposure of the mediastinum and for talc pleurodesis. General anesthesia with two-lung ventilation can be used in any age group but is generally necessary for infants and small children, as they often will not tolerate the collapse of one lung, and in the larger child or adolescent with severe pulmonary compromise.

Congenital diaphragmatic hernia: experience in a single institution from 1978 through 1994

BACKGROUND Congenital diaphragmatic hernia continues to be a difficult management problem. Essentially all information on the condition has been compiled in a retrospective manner due to the individualized care that each infant must undergo. We contribute a review of our patients to add to the current fund of knowledge and to assess our experience before and since the introduction of extracorporeal membrane oxygenation in our institution. METHODS This is a review of records of infants with congenital diaphragmatic hernia treated from 1978 through 1994. Repair has generally been accomplished early with only one repair being accomplished with an infant placed on extracorporeal membrane oxygenation preoperatively. RESULTS Overall survival was 63%. Survival was 42% before extracorporeal membrane oxygenation becoming available in our region in 1986, and 75% afterward. Since 1986, 16 of 33 (48%) infants have required extracorporeal membrane oxygenation and 73% have survived. CONCLUSIONS Overall survival in our series is comparable with that of other reported series. There appears to be an improvement in survival since the introduction of extracorporeal membrane oxygenation. Our present practice of early repair, and postrepair extracorporeal membrane oxygenation if needed, results in a survival rate comparable with that of currently available series reports regardless of the method of treatment reported.

The effects of talc pleurodesis on growing swine

Talc pleurodesis is an effective means of preventing recurrent pneumothorax. We have successfully applied talc pleurodesis with thoracoscopy in children with cystic fibrosis presenting with pneumothorax. However, little is known about the effects of talc pleurodesis on lung compliance in growing children. Therefore, six young pigs (10 weeks old, weighing 15 +/- 1 kg) were prepared for study. In each pig, one hemithorax underwent thoracoscopy and talc pleurodesis (TALC). The other hemithorax underwent either thoracoscopy alone or no procedure (CONTROL). Dynamic and static respiratory mechanics were studied 5 and 10 weeks later. Air flow and airway pressure were measured to calculate dynamic transpulmonary and transrespiratory compliance, and static transpulmonary compliance. At 5 weeks, dynamic transpulmonary and transrespiratory compliance were less in the TALC lungs when compared with CONTROL lungs. At 10 weeks, the differences in dynamic transpulmonary and transrespiratory compliance between the TALC and CONTROL lungs had resolved. Static compliance was lower in the TALC lungs than in the CONTROL lungs at both 5 and 10 weeks, but this was significant only at 10 weeks. There was an improvement in static compliance in the TALC lungs between 5 and 10 weeks, but this only approached significance. At autopsy, there were marked adhesions and pleural thickening in the talc lungs. Histological examination demonstrated no differences in lung parenchyma between the TALC lungs and the CONTROL lungs. Talc pleurodesis causes a temporary impairment in dynamic transpulmonary and transrespiratory compliance that resolves with time and growth. Static compliance is more persistently compromised, but a trend toward improvement with time and growth exists.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful Management of Stage 4s Neuroblastoma and Severe Hepatomegaly Using Absorbable Mesh in an Infant

This report describes the use of an absorbable mesh in an infant with stage 4S neuroblastoma who required decompressive laparotomy. At the time of laparotomy, a SILASTIC silo was placed. After 12 days, the liver had not reduced in size despite chemotherapy and radiation therapy. Because of concern for infection, the silo was removed, and an absorbable polygalactin (Vicryl) mesh was placed. Wet-to-dry dressings were used to manage the mesh. A granulation base developed that provided a physiological closure of the abdominal cavity. Forty-two days after placement of the absorbable mesh, the liver had reduced to a size that permitted mobilization of skin flaps for a surgical abdominal closure. The liver continued to reduce in size, allowing the fascial edges to draw together. The patient is now 2 years old with no signs of residual tumor or ventral hernia.

Surgical management of children with locally advanced hepatoblastoma

We read with great interest the article by Lautz et al titled ‘‘Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma.’’ The authors document excellent results with a difficult subgroup of children with hepatoblastoma. We agree with their conclusion that referral to a center specializing in pediatric hepatobiliary surgery should not be considered a referral for a predestined liver transplant, even if the child has a hepatoblastoma that is extensive and potentially unresectable. Rather, it is a referral to a center where the expertise is available to perform a complex liver resection or a transplant, in children, where it is often not possible to know which is the better treatment in a disease where complete surgical resection is essential for cure. This article points out the challenges of providing definitive surgical care for such children. One child died and 2 of the 13 survivors had major vascular complications: 1 required urgent salvage liver transplant for ischemic cholangiopathy and 1 required a splenorenal shunt for postoperative thrombosis of the portal vein. Even in experienced hands, such major vascular complications will occur. This risk, plus the extensive literature showing improved oncology outcomes with upfront, rather than ‘‘rescue,’’ liver transplant, has driven the increased and highly successful use of liver transplantation in this disease over the past decade. We question the authors’ conclusion that PRETEXT should not be used as a triage tool because it has a tendency to overstage. The PRETEXT system has been used effectively in European SIOPEL [Liver tumor study group of the International Society of Pediatric Oncology (SICP)] multicenter studies to triage those children with aggressive tumors to the centers best able to manage the operative challenges the authors note. SIOPEL multicenter studies 1, 2, and 3 have documented improved patient survival with this approach. In fact, one of the major study objectives of AHEP-0731 is to determine the accuracy of the PRETEXT/POST-TEXT group in predicting surgical resection. Finally, and perhaps most importantly, we would call attention to a small but very important misstatement in the article’s quotation of the surgical guidelines in the current Children’s Oncology Group (COG) protocol AHEP-0731 ‘‘Treatment of Children with all Stages of Hepatoblastoma.’’ In the last sentence on page 1976, the authors state, ‘‘Children with POST-TEXT III and IV tumors are referred to a surgical center with expertise in pediatric liver transplant and extreme liver resection at diagnosis if possible and no later than just after the second cycle of chemotherapy.’’ First, the correct terminology for the chemotherapy classification at diagnosis is PRETEXT; classification after neoadjuvant chemotherapy is POSTTEXT. Second and more importantly is to emphasize that COG AHEP-0731 does not recommend referral of all patients with PRETEXT/POST-TEXT III tumors, only the subset of children with POST-TEXT III tumors who demonstrate persistent major vascular involvement after neoadjuvant chemotherapy. POST-TEXT III tumors without major vascular involvement are considered ‘‘resectable’’ by the COG AHEP-0731 protocol and do not need to be referred to a specialty liver center. AHEP-0731 does recommend referral for all patients with POSTTEXT IV tumors. Because of inferior outcomes seen in previous large multicenter studies, the protocol does not recommend piecemeal nonanatomic resection of these POST-TEXT IV tumors when they aremultifocal. Under ideal circumstances, we would suggest that all children in the United States with hepatoblastoma should be enrolled in AHEP-0731 and wish to assure readers that the COG surgical guidelines are just that: they are guidelines. Our committee would welcome the opportunity to clarify any questions surgeons or oncologists might have regarding this study, which was designed with the goal espoused in the article’s conclusion ‘‘. . .to provide the best oncologic therapy for each individual child while limiting unnecessary long-termmorbidity.’’

Neonatal Congenital Malignant Melanoma With Lymph Node Metastasis

A Caucasian baby girl presented at birth with a dark, irregular, raised skin lesion measuring approximately 2 cm in diameter on the medial aspect of her right leg (Fig 1). There was no history of melanoma in her family and no evidence of melanoma in her mother. At two weeks of age, she underwent an incisional biopsy of the lesion at a community hospital. Histologic review showed a superficial spreading invasive malignant melanoma with Breslow thickness greater than 2.5 mm, with a positive deep margin. There was angiolymphatic invasion but no definite ulceration. She was referred to our institution, where clinical exam revealed an otherwise healthy newborn girl, a black lesion on the right leg with a central scar measuring 1.5 cm in diameter. There were small palpable inguinal nodes in each groin, possibly more prominent on the right but not clinically suspicious. One week later, a wide local excision was performed with a 1 cm margin (Fig 1) and a full thickness skin graft. Lymphoscintigraphy revealed a sentinel node in the right groin, and a sentinel lymph node biopsy was performed. Her final pathology revealed an atypical malignant melanoma arising in a nevus with congenital features with Breslow thickness of 2.58 mm and Clark’s level V (Fig 2A). Margins were widely clear. The lesion was consistent with a primary melanoma, rather than metastatic disease from maternal origin. The sentinel node was positive for metastatic melanoma, with mitotic figures (Fig 2B) and S100 staining (Fig 2C). She underwent staging studies including CT scans of her head, chest, abdomen and pelvis as well as a bone scan. These were negative for metastatic disease. One month later, completion right inguinal lymph node dissection was performed, yielding five lymph nodes without metastatic disease. Her postoperative course was complicated by a wound abscess in the right groin that was drained operatively and healed well. Her final staging, at the age of 9 weeks, was therefore Stage IIIA (T3aN1aM0). No additional treatment was performed. She has been followed to her current age of 32 months without evidence of recurrence by clinical exam, serial chest radiographs, and annual CT scans of the abdomen and pelvis. She has had an excisional biopsy of a suspicious skin lesion from her lower abdomen at age 22 months that was an atypical nevus. She has normal function of her right lower extremity without lymphedema and is healthy and developmentally appropriate (Fig 3).

Bronchoscopic Obliteration of Recurrent Tracheoesophageal Fistula in an Infant

This report describes the use of cautery and fibrin glue applied via rigid bronchoscopy to obliterate a recurrent tracheoesophageal fistula (TEF) in an infant who had undergone repair of congenital esophageal atresia and TEF without a proximal fistula on day of life (DOL) 2 by division of the TEF with end-to-end anastomosis of the esophagus. She fed uneventfully and was discharged on DOL 11. Two months later, the child began coughing while feeding, and a contrast study showed a recurrent TEF. She underwent rigid bronchoscopy and cauterization of the fistula with an insulated wire followed by application of fibrin glue. This procedure was carried out three times at weekly intervals. Feeding was accomplished via nasogastric tube. The patient continues to eat well almost 3.5 years later. Recurrent TEF may be obliterated with application of cautery and fibrin glue via rigid bronchoscopy. Thoracotomy may thereby be avoided.