Philip J Wolfson

Right common carotid artery reconstruction after extracorporeal membrane oxygenation : vascular imaging, cerebral circulation, electroencephalographic, and neurodevelopmental correlates to recovery

OBJECTIVE Right common carotid artery (RCCA) ligation after extracorporeal membrane oxygenation by venoarterial bypass may contribute to lateralized cerebral injury. Reconstruction of this artery after extracorporeal membrane oxygenation has proved feasible but has not been evaluated for neurologic outcome in any substantial series of infants. METHODS We evaluated RCCA reconstruction in 47 infants treated with ECMO and compared their cerebrovascular and neuroanatomic imaging findings, electroencephalograms, and developmental outcomes with those of 93 infants who had no reconstruction. SUMMARY RESULTS: Color Doppler blood flow imaging revealed that carotid artery patency was usually obtained after RCCA reconstruction. Right internal carotid and bilateral anterior and middle cerebral arterial blood flow velocities were generally higher, and were more symmetrically distributed in infants with reconstructed RCCA. Electroencephalography did not disclose an increased risk of deterioration or marked abnormalities in infants after reconstruction, nor were neuroimaging findings consistent with an increased number of either focal or generalized abnormalities. Neurodevelopmental follow-up revealed no differences in the incidence of delays between those with a reconstructed RCCA and those with a ligated RCCA during the first year of life. CONCLUSIONS Reconstruction of the RCCA after extracorporeal membrane oxygenation may facilitate normal distribution of cerebral blood flow through the circle of Willis, and may augment both left and right middle cerebral artery blood flow immediately after decannulation. The long-term consequences of either ligation or reconstruction of the RCCA will require careful scrutiny, however, before either course is recommended routinely.

Gastric volvulus after laparoscopic Nissen fundoplication with gastrostomy.

The authors present the case report of a 13-year-old boy in whom organoaxial gastric volvulus developed four months after a laparoscopic Nissen fundoplication and placement of gastrostomy. Intraoperative findings were significant for volvulus about an axis defined by 2 fixation points, one at the fundoplication site and the other in the area of the gastrostomy tube, positioned close to the pylorus. Of the 142 pediatric cases of gastric volvulus reported to date, only 7 describe it as a complication subsequent to gastric surgery, and just one case has been reported after laparoscopic Nissen fundoplication. This case shows that fundoplication and gastrostomy, a recommended treatment for gastric volvulus, does not always preclude its development. Increasing numbers of pediatric surgeons are performing laparoscopic Nissen fundoplication procedures. The authors advise surgeons to consider this potentially fatal complication, both intraoperatively when selecting a location for gastrostomy and postoperatively when evaluating complaints.

3-Year-old phenotypic female with campomelic dysplasia and bilateral gonadoblastoma

The authors report the case of bilateral gonadoblastomas in a phenotypic female, with a 46,XY karyotype, with campomelic dysplasia. Although campomelic dysplasia with gonadal dysgenesis should be expected to contribute to an increased risk of gonadoblastoma, this is the first documented case report of campomelic dysplasia and gonadoblastoma. Phenotypic females with campomelic dysplasia should be karyotyped once the skeletal dysplasia is recognized. phenotypic females with campomelic dysplasia should undergo gonadectomy if their karyotype includes a Y chromosome or fragment.

Dumbbell neuroblastoma presenting without spinal cord findings

Patients with dumbbell neuroblastoma present with a wide variety of spinal cord problems. We recently treated an infant with a large dumbbell neuroblastoma who was neurologically intact. Because a CAT scan showed a retroperitoneal mass to be abutting the right vertebral body at T12-L1, a precautionary myelogram was performed, which revealed extensive intraspinal extension. We report this case to emphasize the need to have a high index of suspicion of spinal cord involvement in light of a normal neurologic examination since, any attempt at removing the extraspinal part, first, could cause serious neurologic sequelae. We also wish to emphasize avoiding radiation therapy when the tumor has been removed grossly to lessen the development of kyphoscoliatic deformity. The infant will be routinely followed with serial VMAs and ultrasound.

Five-Year Outcome Following Carotid Artery Reconstruction after ECMO |[dagger]| 1238

Objective: We evaluated long-term arterial patency and neurodevelopmental outcome in infants whose right common carotid artery (RCCA) was reconstructed following ECMO.

Significant Anomalies and Recurrence Rate Revealed by Follow-up Radiographic Screening after Neonatal Repair of Congenital Diaphragmatic Hernia in the ECMO Era |[dagger]| 1208

Objective: To determine the recurrence rate of congenital diaphragmatic hernia (CDH), and to reveal any additional developmental lung or thoracic anomalies, we reviewed follow-up chest radiographs in survivors who underwent neonatal repair after ECMO therapy had been introduced into our intensive care nursery.