Klaus Schaarschmidt

Thoracoscopic repair of congenital diaphragmatic hernia by inflation-assisted bowel reduction, in a resuscitated neonate: a better access?

Elective endoscopic diaphragmatic hernia repairs have been reported. But endoscopic surgery was regarded unsuitable for emergency repair of diaphragmatic hernia in ventilated newborn children in bad general condition. We report a new method for inflation-assisted reduction and thoracoscopic repair of congenital diaphragmatic hernia diaphragmatic in a vitally endangered neonate. From three 2.7xa0mm to 5xa0mm accesses warmed low-pressure, low-volume CO2 was inflated into the thorax at 100xa0ml/min and 2xa0mm mercury. This allowed spontaneous reduction of the thoracic viscera into the abdomen and diaphragmatic suture with minimal handling. The 65-min procedure was tolerated well without perioperative deterioration. The baby was weaned off the respirator and breast-fed within 2xa0days, mediastinal shift normalized in 6xa0days. In suitable infants thoracoscopic repair and inflation-assisted reduction of thoracic contents is a more physiological access to congenital diaphragmatic hernia than laparoscopy or laparotomy.

New Berlin-Buch "reversed Nuss," endoscopic pectus carinatum repair using eight-hole stabilizers, submuscular CO2, and presternal Nuss bar compression: first results in 35 patients.

INTRODUCTIONnSince 2001 we minimized access (2.9-4.7u2009cm) for universally applicable endoscopic hybrid carinatum technique with two transsternal Willital bars in 173 endoscopic hybrid (EH) patients with very satisfactory results. In 2008-2009, endoscopic Nuss bar compression with endoscopic repair of costal flaring applied a new eight-hole stabilizer, which allows the use in pectus carinatum (PC) beyond adolescence including redos and combined deformities. This prospective study of 35 endoscopic Berlin-Buch reversed Nuss repairs intends to establish indications for this improved technique.nnnMATERIALS AND METHODSnIn February 2008 to February 2010, we used endoscopic Nuss bar compression by applying a bilateral new eight-hole stabilizer fixed to the bar without screws or wires, which allows unprecedented versatility and the use in pectus carinatum beyond adolescence. Thirty-five patients aged 17.05u2009±u200910.2 years (range: 11.3-33.1 years) were recorded prospectively and followed at 3 monthly intervals. We implanted a standard Nuss bar (11-14) into an endoscopically dissected submuscular presternal pocket correcting PC by sternal pressure. The bars were put under tension by traction via bilateral eight-hole stabilizers and three pericostal wire sutures on each side. Bars were removed after 2 years.nnnRESULTSnAll 35 reversed Nuss pectus carinatum repairs, including 2 redos after Ravitch, were successful, with no conversion. So far there was no local or general complication and no seroma or bar dislocation. Thirty-one patients judged their result as excellent and 4 as good.nnnCONCLUSIONSnAlthough this is a very early experience, reversed Nuss is safe and effective and new technical improvements have expanded the range of applicability to older patients and suitable redos.

Abdominal inflammatory masses mimicking neoplasia in children—experience of two centers

Despite progress in modern imaging, some inflammatory masses are difficult to distinguish clinically from neoplastic processes. In such cases the pathology report has a great distinctive value, but even then the final diagnosis may be difficult to reach. Eight patients with abdominal tumors of inflammatory origin were treated in two institutions, the Department of Pediatric Surgery of the Medical University of Gdansk, Poland, and Helios Center of Pediatric Surgery in Berlin, Germany, during the last 10xa0years. Four tumors were located in the pelvis, two in the liver, and two in the colonic mesentery. Five of them were inflammatory pseudotumors (two subclassified as inflammatory fibrosarcoma), one had nonspecific inflammatory changes, one was diagnosed as idiopathic retroperitoneal fibrosis, and one was diagnosed as bacillary angiomatosis. All patients underwent surgical tumor biopsy, excisional in four and incisional in four. All but two children underwent macroscopically complete tumor excision (four primarily, two secondarily). In one case the tumor resolved with antibiotherapy. Surgery in retroperitoneal masses was often extensive and associated with significant complications because of invasive tumor growth. In conclusion, intraabdominal inflammatory lesions may closely mimic neoplasia in children. Clinical doubts result in repeated biopsies, and for this reason excisional biopsy should be preferred. In some cases, when excisional biopsy is not feasible due to invasive growth of the tumor, delayed complete mass excision should follow, despite occasional significant morbidity. The etiology and exact nature of inflammatory pseudotumors are still obscure, and it is unknown whether they represent inflammatory lesions or true neoplasia.

Impact of surgical correction of pectus excavatum on cardiac function: insights on the right ventricle. A cardiovascular magnetic resonance study †

OBJECTIVESnPectus excavatum (PE) is often regarded as a cosmetic disease, while its effect on cardiac function is under debate. Data regarding cardiac function before and after surgical correction of PE are limited. We aimed to assess the impact of surgical correction of PE on cardiac function by cardiovascular magnetic resonance (CMR).nnnMETHODSnCMR at 1.5 T was performed in 38 patients (mean age 21 ± 8.3; 31 men) before and after surgical correction to evaluate thoracic morphology, indices and its relation to three-dimensional left and right ventricular cardiac function.nnnRESULTSnSurgery was successful in all patients as shown by the Haller Index ratio of maximum transverse diameter of the chest wall and minimum sternovertebral distance [pre: 9.64 (95% CI 8.18-11.11) vs post: 3.0 (2.84-3.16), P < 0.0001]. Right ventricular ejection fraction (RVEF) was reduced before surgery and improved significantly at the 1-year follow-up [pre: 45.7% (43.9-47.4%) vs 48.3% (46.9-49.5%), P = 0.0004]. Left ventricular ejection fraction was normal before surgery, but showed a further improvement after 1 year [pre: 61.0% (59.3-62.7%) vs 62.7% (61.3-64.2%), P = 0.0165]. Cardiac compression and the asymmetry index changed directly after surgery and were stable at the 1-year follow-up [3.93 (3.53-4.33) vs 2.08 (1.98-2.19) and 2.36 (2.12-2.59) vs 1.38 (1.33-1.44), respectively; P < 0.0001 for both]. None of the obtained thoracic indices were predictors of the improvement of cardiac function. A reduced preoperative RVEF was predictive of RVEF improvement.nnnCONCLUSIONSnPE is associated with reduced RVEF, which improves after surgical correction. CMR has the capability of offering additional information prior to surgical correction.

Lessons Learned From Lethal Cardiac Injury by Nuss Repair of Pectus Excavatum in a 16-Year-Old

This report investigates cardiac injury and arrest during a Nuss repair of severe pectus excavatum in a 16-year-old boy in 2006. The injuries of the right atrial auricle and the right ventricle were sutured, and the patient was resuscitated. Ultimately he died on the 11th day of progressive malignant cerebral edema and respiratory distress syndrome despite cerebral decompression and hypothermia. Typical morphologic features of cardiac injuries are demonstrated, and strategies to avoid inadvertent organ injury in pectus operations are discussed.

Re-evaluation of histological findings of nonparasitic splenic cysts

Objective The pathogenesis of nonparasitic splenic cysts (NPSCs) has not been clarified completely. The aim of this multinational and multicentre retrospective study was to further elucidate the origin of NPSCs. Methods From 1980 to 2006, 50 children and adolescents were surgically treated for NPSC at six paediatric surgical centres in four European countries. The initial histology report of 35 NPSCs, 22 epidermoid cysts, 11 pseudocysts or post-traumatic cysts and two mesothelial cysts was available. Additional re-evaluation, including immunohistochemistry, to detect cytokeratin, carcino-embrionic antigen and mesothelioma antibody in the inner surface of the cysts was carried out. Special attention was given to the possibility of preceding trauma to the splenic area and whether it played a role in the genesis of NPSC. Results The pathological re-evaluation showed 30 epidermoid cysts, four mesothelial cysts and one pseudocyst. Immunohistology revealed eight epidermoid and two mesothelial linings of the cysts in those 11 patients in whom pseudocyst was diagnosed originally. No pseudocyst was documented in those patients who had a history of previous blunt abdominal trauma but was not proved by ultrasound and computed tomography scan. Conclusion In contrast with the prevailing belief, it has been demonstrated that NPSCs are congenital in origin, and there is no clinically proven evidence that trauma does play a role in their genesis.

Hemodynamic impact of surgical correction of pectus excavatum - a cardiovascular magnetic resonance study

HELIOS Klinikum Berlin-Buch, Charite Campus-Buch, Humboldt University, Berlin, Germany Full list of author information is available at the end of the article Figure 1 Upper row: Axial SSFP-images before (left) and after (right) surgery Lower row: Short axis SSFP-images before (left) and after (right) surgery. Zagrosek et al. Journal of Cardiovascular Magnetic Resonance 2011, 13(Suppl 1):P190 http://jcmr-online.com/content/13/S1/P190

Cardiac magnetic resonance in patients with pectus excavatum: impact of thoracic surgery on cardiac function - a follow- up-study

Background Pectus excavatum (PE) as the most common anterior chest deformity is characterized by sternal depression with corresponding leftward displacement and rotation of the heart which is troublesome for assessment by ultrasound. Therefore CMR plays a growing role in preoperative evaluation. Indication for surgical correction is based on a diameter-based assessment of the thorax (Haller-Index, HI) and symptoms. Imaging data describing cardiac performance after surgery are rare. The aim of the study was to assess cardiac function during follow-up (FU). Methods 37 patients with PE (30 male, age 12-43 years) underwent CMR using 1.5T MRI-scanner (Avanto, Siemens Healthcare, Germany) prior to surgery and repeatedly postoperative (10 days, 3 months and 1 year). The highly experiences surgeons (more than 130 procedures/year) implanted a titan-bar (Nuss procedure) based on the usual clinical indication. CMR protocol included state of the art cine SSFP covering the left ventricle (LV) as short axis (TR 33.6 ms, TE 1.18 ms, FOV 292 × 360 mm, matrix 256 × 208, sth 7 mm without gap) and the right ventricle (RV) axial orientation (TR 34.56 ms, TE 1.21 ms, FOV 332 × 269 mm, matrix 256 × 208, sth 6 mm without gap). HI was measured on survey images (Figure 1). We quantified the enddiastolic and endsystolic volumes of LV and RV: calculated the ejection fractions (EF) and stroke volumes (SV) using CMR42 (circle cvi, Canada). Results CMR images were evaluable despite implanted titanium bars. All patients completed one year FU. HI was significantly reduced after surgery (pre: 9.9 ± 5.7 vs. post: 2.8 ± 0.5, p < 0.001) indicating a successful procedure. Pleural effusions were detectable at day 10 in almost all (24 from 25 patients) pericardial effusion in 3 and it was resolved in all completely after 1 year. There were variable findings at different FU-time-points. The most positive change in RVEF was observed at 10 days FU followed by slight reduction on 3 months and further decrease at 1 year. Despite these findings the RVEF remained significantly improved at 1 year. Interestingly, RVEF was found to change significantly from baseline to 1 year FU (p < .0001), whereas LVEF did not (p = 0.0539). RVSV and LVSV were found to change significantly from baseline to 1 year follow-up (p = 0.0018 and 0.0008, respectively). Weak correlation was found between the delta (baseline/1 year) HI compared to RVEF.

Laparoscopic Repair of Paraesophageal Hiatal Hernia in a Newborn

Laparoscopic Repair of Paraesophageal Hiatal Hernia in a Newborn A 3-month old boy was hospitalized with the suspicion of right sided pneumonia. Examination revealed hiatal or paraesophageal hernia. Ultimately, a laparoscopic operation was performed. During the operation, PEHH of the transverse colon with displaced gastro esophageal junction was discovered. Laproscopic hiatal hernia repair with modified Thal fundoplication were performed. Recovery of child 2 years after surgery was uneventful.