Klaas M. A. Bax

Congenital diaphragmatic hernia: to repair on or off extracorporeal membrane oxygenation?

BACKGROUND Congenital diaphragmatic hernia (CDH) can be repaired on or off extracorporeal membrane oxygenation (ECMO). In many centers, operating off ECMO is advocated to prevent bleeding complications. We aimed to compare surgery-related bleeding complications between repair on or off ECMO. METHODS All patients with CDH repair and ECMO treatment between January 1, 1995, and May 31, 2008, were retrospectively reviewed. Tranexamic acid was routinely given to all patients repaired on ECMO for 24 hours perioperatively after 2003. Extra-fluid expansion, transfusion, or relaparotomy caused by postoperative bleeding were scored as surgery-related bleeding complications and were related to the Extracorporeal Life Support Organization (ELSO) registry. We used χ(2) test and t test for statistics. RESULTS Demographic data and surgery-related bleeding complications in the on-ECMO group were not significantly different compared with the off-ECMO group (P = .331) in our institute. In contrast, more surgery-related bleeding complications were reported by ELSO in their on-ECMO group (P < .0001). CONCLUSION In contrast to the data from the ELSO registry, we did not observe significantly more surgery-related bleeding complications after CDH repair on ECMO. Using a specific perioperative hemostatic treatment enabled us to perform CDH repair on ECMO with a low frequency of bleeding complications, thereby taking advantage of having the physiologic benefits of ECMO available perioperatively.

Optimizing working space in laparoscopy: CT measurement of the influence of small body size in a porcine model

INTRODUCTION In our continuing research into the determinants of laparoscopic working space, the influence of small body size was investigated. METHODS In eight 6-kg pigs, the effects of intraabdominal CO2 pneumoperitoneum pressure (IAP), prestretching of the abdominal wall, and neuromuscular blockade (NMB) on laparoscopic working space volume and distances were studied. Computed tomography was used to measure working space during two stepwise abdominal insufflation-runs up to an IAP of 15mm Hg. Results were compared with data from earlier experiments in 20-kg pigs. RESULTS Cardiorespiratory parameters were stable up to an IAP of 8-10mm Hg. In 6-kg pigs working-space dimensions were five times smaller than in 20-kg pigs. Working-space volume, anteroposterior (AP) diameter and symphysis-diaphragm distance increased linearly up to an IAP of 8mm Hg. Above 8mm Hg, compliance decreased. Eighty percent of the total volume (618ml) and of AP diameter (3cm) at 15mm Hg had been achieved at an IAP of 10mm Hg. Prestretching by a first insufflation resulted in a statistically significant increase in working space volume and in AP diameter during the second insufflation. This effect was significantly larger than in 20-kg pigs. Neuromuscular blockade did not have a significant effect on working-space. CONCLUSIONS Working space in growing individuals is very limited. Eighty percent of the working space created by an IAP of 15mm Hg was already achieved at 10mm Hg, while cardiorespiratory side effects at an IAP of 8-10mm Hg seem acceptable. Prestretching of the abdominal wall significantly increased working space, even more so than in 20-kg pigs. As in 20-kg pigs, NMB had no significant effect on laparoscopic working space. Prestretching of the abdominal wall is a promising cheap, safe and easy strategy to increase laparoscopic working space, lessening the need for prolonged high-pressure pneumoperitoneum.

Esophageal Replacement with Jejunum in Children

Reconstruction of the esophagus in children, when a larger part of the esophagus is absent or has been destructed, is still a challenge [1–3]. The most important indications for such a reconstruction in children are esophageal atresia (EA, either as a primary reconstruction in pure EA or after failed anastomotic attempts in AE/TEF) or destruction of the esophagus by accidental or suicidal ingestion of a caustic substance. Occasionally a peptic stricture may require esophageal replacement as well. Patients with such indications differ significantly in terms of characteristics: Patients with EA are mostly newborns or infants. When the newborn cannot swallow properly for a prolonged period of time, feeding difficulties persist even after esophageal reconstruction [4]. Early restoration of the esophagus seems therefore important. In contrast patients with extensive esophageal strictures due to caustic injuries or reflux esophagitis are usually much older and have swallowed properly before.

Esophageal Atresia Repair

Thoracoscopic repair of esophageal atresia is a technically demanding surgical procedure which is gaining popularity for this anomaly. The procedure requires special short instruments of small diameter suitable for manipulation in the newborn thorax. The chapter outlines the operation room setup, positioning of the patient, special instruments required for the procedure and the port placement sites. The indications, contraindications, preoperative considerations and technical considerations during thoracoscopic repair of esophageal atresia have been listed. The surgical procedure has been explained step-by-step using high quality images.