Gary E. Hartman

Peritoneal drainage as primary management of perforated NEC in the very low birth weight infant

Advances in perinatal and neonatal care in the past decade have produced a change in the population of infants with perforated necrotizing enterocolitis (NEC) treated at our institution: the majority are now of very low birth weight (VLBW, < 1,000 g). Peritoneal drainage has been reported as an initial resuscitative procedure for unstable infants who have complicated NEC. Initial success with peritoneal drainage prompted us to adopt an aggressive approach to its use in this patient population. Since 1987, peritoneal drainage has been the primary treatment for most infants weighing less than 1,500 g who have perforation, and for unstable infants weighing more than 1,500 g. Perforation was documented by pneumoperitoneum or aspiration of meconium by paracentesis. Intestinal resection was performed in most infants weighing more than 1,500 g and in those for whom drainage was ineffective. Twenty-nine infants with low or VLBW (mean gestational age, 27 weeks; mean birth weight, 994 g) were treated with one or two drains in the right lower quadrant. Broad spectrum antibiotics were continued until all drains were removed, usually within 10 to 14 days. Nasogastric suction was continued until patency of the gastrointestinal (GI) tract was confirmed by a nonionic upper GI series. Six (21%) infants died, although one of the deaths occurred 5 months after drainage; the patient had chronic lung disease and an intact GI tract. Seventeen of the 23 (74%) survivors required no further operative procedure, and 6 (26%) required laparotomy and resection because drainage had been ineffective. Peritoneal drainage provided definitive treatment in 18 of 29 (62%) infants in this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of septic complications associated with silastic® catheters in childhood malignancy

From January, 1979, to December, 1984, 63 Hickman or Broviac catheters were inserted into 50 high risk pediatric oncology patients (median age, 37 months). Catheters remained in place for an average of 241 days. Possible catheter sepsis and exit site infection accounted for the majority (39 of 76) of the complications of long term central venous catheterization. Neutropenia (absolute neutrophil count under 500/mm3) was associated with 70% of the catheter-related infections and 75% of the non-catheter-related infections. Catheters inserted during neutropenic episodes (23) were associated with an increased risk of subsequent septicemia (60% vs. 25%), a finding apparently related to their exposure to further neutropenia (38% vs. 16% catheter days). Of the 32 episodes of septicemia of unknown origin, 19 involved Gram-negative bacteria, 14 involved Gram-positive bacteria and 4 were caused by fungi. Five of these episodes involved multiple organisms. Staphylococcus epidermidis was the most common Gram-positive organism isolated (7 of 14). Four episodes of septicemia resolved before therapy and are considered false positive cultures. Of the other 28 episodes of septicemia, 25 (89%) were successfully treated without catheter removal including 3 episodes of fungemia and 4 of multiple organism sepsis. These data demonstrate the efficacy of antimicrobial treatment without catheter removal in the pediatric oncology population with catheter-associated infections including those associated with neutropenia, multiple organisms and fungemia.

Early hernia repair in the premature infant: long-term follow-up.

The incidence of inguinal hernia and incarceration is high among premature infants. Optimal timing, anesthetic technique, and long-term results of hernia repair in hospitalized premature infants remain undefined. The authors reviewed the records of 52 consecutively treated premature infants who underwent bilateral inguinal herniorrhaphy under general anesthesia before discharge from the intensive care nursery. There were no significant differences in gestational age, birth weight, age and weight at time of surgery, or presence of preoperative apnea or bradycardia in between infants extubated within 24 hours and those intubated for more than 24 hours. Twenty-four infants (46%) were available for follow-up of 24 months or more (mean follow-up period, 57 months). One recurrence was identified, representing 4% of the long-term follow-up group and 2% of the initial population. Two patients had asymmetric testicular volumes suggestive of unilateral atrophy. The short- and long-term results suggest that repair under general anesthesia can be safely performed before discharge from the intensive care nursery.

Outcomes of sutureless gastroschisis closure

INTRODUCTION A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures. METHODS AND PATIENTS A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications. RESULTS In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients. CONCLUSION Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.

Post-necrotizing enterocolitis strictures presenting with sepsis or perforation: risk of clinical observation.

Intestinal stenosis or stricture occurs in approximately one third of medically treated infants surviving the acute phase of necrotizing enterocolitis (NEC). Identification of these lesions by the use of routine contrast enemas has been advocated as a means of decreasing potential morbidity from delayed diagnosis. However, the significant incidence of spontaneous resolution and reluctance to submit asymptomatic infants to contrast enema have led recent researchers to reserve these studies for patients developing symptoms of obstruction during a period of close observation. From July 1984 to July 1986, symptomatic strictures developed in five infants (15%) responding to medical management at our institution. Contrast enemas were not routinely performed and four (80%) of these patients presented with life-threatening sepsis or perforation associated with intestinal obstruction. Two infants developed complete colonic obstruction 4 and 6 weeks after discharge from the Intensive Care Nursery, having initially tolerated oral feedings. Both infants were critically ill due to perforation or sepsis and underwent emergency colostomy at community hospitals. Two other infants developed abdominal distension with sepsis and cardiopulmonary decompensation while remaining hospitalized for prematurity and pulmonary insufficiency. These patients became symptomatic 5 and 7 weeks after cautious refeeding while closely monitored in the Intensive Care Nursery. The occurrence of such life-threatening complications suggests that clinical observation alone is not adequate in the management of many of these infants. Contrast enemas should be performed to identify those patients at risk of such potential morbidity or mortality, especially those infants not residing near pediatric surgical facilities.

Lobar lung transplantation as a treatment for congenital diaphragmatic hernia

The mortality rate for infants severely affected with congenital diaphragmatic hernia (CDH) remains high despite significant advances in surgical and neonatal intensive care including delayed repair and extracorporeal membrane oxygenation (ECMO). Because of the increasingly successful experience with single-lung transplantation in adults; this approach has been suggested as a potential treatment for CDH infants with unsalvageable pulmonary hypoplasia. The authors report on a newborn female infant who was the product of a pregnancy complicated by polyhydramnios. At birth, she was found to have a right-sided CDH and initially was treated with preoperative ECMO, followed by delayed surgical repair. Despite the CDH repair and apparent resolution of pulmonary hypertension, the infants condition deteriorated gradually after decannulation, and escalating ventilator settings were required as well as neuromuscular paralysis and pressor support because of progressive hypoxemia and hypercarbia. A lung transplant was performed 8 days after decannulation, using the right lung obtained from a 6-week-old donor. The right middle lobe was excised because of the size discrepancy between the donor and recipient. After transplantation, the patient was found to have duodenal stenosis and gastroesophageal reflux, which required duodenoduodenostomy and fundoplication. The patient was discharged from the hospital 90 days posttransplantation, at 3 1/2 months of age. Currently she is 24 months old and doing well except for poor growth. This case shows the feasibility of single-lung transplantation for infants with CDH, and the potential use of ECMO as a temporary bridge to transplantation. Lobar lung transplantation allowed for less stringent size constraints for the donor lung.

Sonographic detection of congenital pancreatic cysts in the newborn: Report of a case and review of the literature

A case of congenital pancreatic cysts detected antenatally by ultrasound is presented. This is the second case detected antenatally. Congenital pancreatic cysts should be included in the differential diagnosis of upper abdominal cystic masses in the fetus and newborn infant.

Severe lactic acidosis and multiorgan failure due to thiamine deficiency during total parenteral nutrition

A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.

Extra-adrenal pheochromocytoma: An unusual location

A 14-year-old boy with a retrohepatic para-aortic pheochromocytoma demonstrates the potential difficulties of localization in an unusual extra-adrenal site of pheochromocytoma. Ultrasonography, computed tomography, metaiodobenzylguanidine scanning, and angiography with venous sampling failed to define the true anatomic location of this tumor. Collateral venous drainage produced confusing venous sampling data and represents a potential pitfall in the interpretation of these studies.

Moiré phototopography in the evaluation of anterior chest wall deformities

One of the major remaining problems in the management of children with anterior chest wall deformities is the lack of a widely accepted objective method of evaluating the severity of the deformity. This deficiency has made it difficult to evaluate indications for operation or the results of operative repair. Moiré phototopography is a new method of accurately measuring human body contours utilizing recent developments in applied optics and has been used successfully in scoliosis screening programs. This technique has been applied to the evaluation of anterior chest wall deformities and the initial results of this study are presented. Moiré phototopography has proven to be a sensitive, reproducible, and easy to perform method of quantitating pectus deformities. While further evaluation is required, this early experience suggests this technique may provide a means of accurately and objectively measuring chest wall deformities so that their physiologic significance can be precisely investigated and the results of therapy critically reviewed.