Quentin R. Stiles

Options in the management of perforations of the esophagus

A study of 90 cases of esophageal perforation in the antibiotic era emphasizes individualized treatment and options of therapy based on a fundamental understanding of modifying pathophysiologic factors. If the patient is seen during the first 24 hours, surgical repair and irrigating tube drainage continue to be the treatment of choice in the thoracic and abdominal regions, with certain exceptions. The exceptions include small perforations proved by a thin media esophagram or esophagoscopy without pleural involvement or constitutional symptoms. Such patients may be treated nonoperatively, with gastric drainage, antibiotics, and parenteral alimentation. However, for large perforations with extensive contamination of the mediastinum and pleura, an esophageal exclusion operation may be life saving. In the cervical region, irrigating tube drainage may be just as effectual as repair and drainage. In patients seen after 24 hours, size of the perforation and the amount of mediastinopleural infection, rather than the time that has elapsed, dictate optimal treatment.

Renal homotransplantation in children

Twenty-three children, aged 2 to 17 years, received 24 renal homotransplants from both live related donors and cadaver donors. Twenty-two children and 19 kidneys are surviving 1 to 32 months after transplantation. The clinical course of renal transplantation in children is described.

Current techniques for chest wall reconstruction: expanded possibilities for treatment.

Myocutaneous flaps and prosthetic materials have greatly facilitated reconstruction after massive chest wall resection. This series includes 112 such procedures. Latissimus dorsi, rectus abdominis, omental, pectoralis major, and contralateral breast flaps were used in 80 patients. Early in the series, 3 flaps were lost because of technical problems. Minor areas of incomplete healing that resolved completely with local wound care occurred in 16 of 80 flaps. Skeletal reconstruction was performed in 82 patients without complication. Marlex mesh was used for flat surfaces, and Marlex mesh with methyl methacrylate was used for the sternum and the curved surface of the lateral chest wall. These results have allowed an expansion of the indications for chest wall resection to include the curative treatment of primary chest wall tumors and palliative treatment for breast cancer patients with osteoradionecrosis, local recurrence (in select patients), chest wall infection, and tumors metastatic to the chest wall.

Pleural Empyema in Children

n the late 1950’s a tremendous increase in the incidence of staphylococcal pneumonia and empyema occurred throughout many of the I pediatric centers in the country. This increase was thought to have been caused by the emergence of antibiotic-resistant strains of bacteria [3]. Several papers appeared in the literature reflecting this changing pattern [4, 6, 71, and some strict rules for surgical management were advised in order to decrease mortality in this disease [6]. Formerly, this mortality ranged from a high of 100% in some series [l] to about 25% in other centers [5, 61. The generally accepted surgical routine was to insert a chest tube in all children who exhibited pleural fluid containing gram-positive cocci. This was followed frequently by conversion to open drainage with or without rib resection, and finally decortication if there was no definite improvement in two or three weeks and a captive lung was assumed to be present. Strict adherence to these principles brought the mortality down to around 10 or 12% [6]. Since about 1962, pleural empyema in children, particularly that due to staphylococci, has become less virulent, probably entirely as the result of newer antibiotic agents. Now certain transgressions can be taken from the older rules of management in order to shorten the hospital stay and decrease the discomfort of these children. It is the purpose of this paper to review the experience with all children diagnosed as having primary pneumonia and secondary empyema over the past 20 years at the Children’s Hospital of Los Angeles, in order to compare present-day management with that practiced 10 years ago.

Management of injuries of the thoracic and abdominal aorta

Thirty-five patients had surgery for injuries of the aorta at the Los Angeles County-USC Medical Center over a 4 1/2 year period. There were 27 survivors. The principles of management were to operate without delay if there was evidence of continued bleeding after initial fluid replacement as occurred in 11 patients. For the 24 patients who became stable after initial resuscitation, a more deliberate plan of management was used. Blood pressure was carefully monitored and controlled to avoid hypertension. Priorities for associated injuries were established and in several cases, they took treatment precedence over the aortic injury. Delay was sometimes necessary to utilize the more experienced personnel. In no instance did a stabilized patient hemorrhage during the delay. The most common injury seen was a blunt disruption of the proximal descending aorta. The details of the operative technique for this injury have been reported herein, along with a justification for not using either pump bypass or shunt to perfuse the distal aorta during the period of aortic cross-clamping.

Renal transplantation in young children

Abstract Thirty-one children, aged one and a half to twelve years, received thirty-six renal allografts from fourteen living related donors, one living unrelated donor, and twenty-one cadaver donors during a five year period of study. Twenty-five of the thirty-one children (81 per cent) are presently alive with functioning allografts (twenty first and five second transplants); five children (16 per cent) have died and one child (3 per cent) is undergoing repetitive hemodialysis while awaiting a subsequent graft. The medical and surgical complications and rehabilitative aspects of the treatment program are delineated in detail to emphasize the acceptability of young children as candidates for renal transplantation.

Cardiopulmonary arrest: Evaluation of an active resuscitation program☆

Abstract Cardiopulmonary resuscitation efforts in response to an emergency call are analyzed as to effectiveness in 302 patients. Over a seven year period there had been a marked improvement in the success rate of resuscitation. The reasons for this are the recognition of the patients most likely to suffer cardiac arrest and the monitoring of these patients closely in special units where nurses trained in resuscitation are constantly in attendance.

Renal artery stenosis in pediatric transplant recipients.

From 1967 through 1985, 400 cadaveric transplants were performed at Children Hospital of Los Angeles. Of these 400, 31 were later identified as having renal artery stenosis. No live related graft developed RAS. Of the 31 grafts, 11 were from donors less than 2 years of age. The major feature suggesting stenosis was hypertension: either persistent or a sudden exacerbation often associated with hypertensive encephalopathy. In individuals with hypertension without obvious cause, renal angiography should be promptly conducted under controlled conditions to avoid complications. The stenotic lesion involved 13 end-to-end and 19 end-to-side arterial anastomoses. Surgery for revascularization of RAS was performed in 21 of 31 with success or improvement in 14, no change in 2, and graft loss in 5. Percutaneous transluminal angioplasty was performed in 4. Two were unsuccessful, 1 was successful and 1 graft was lost. The 7 remaining patients were treated medically.

CADAVERIC RENAL TRANSPLANTATION IN CHILDREN

Abstract 29 children aged 18 months to 18 years received 32 cadaveric renal transplants between February, 1968, and August, 1970. 25 children (86%) and 22 allografts (69%) are surviving 6 to 32 months after transplantation. Growth has occurred in 4 of 5 children whose bone age was less than 12 years at the time of transplantation and who survived more than a year with good allograft function. Knowledge of the source of the kidney did not interfere with emotional adjustment or rehabilitation.

SAPHENOUS VEIN AUTOGRAFT ARTERIOVENOUS FISTULA FOR EXTENDED HEMODIALYSIS IN CHILDREN

Twenty‐two saphenous vein autograft arterio‐venous (A‐V) fistulas were constructed in 21 patients aged 6 9/12 to 20 8/12 years. Clotting resulted in fistula failure in 4 instances, 16 fistulas have been utilized for repetitive hemo‐dialysis for 1 to 11 months, 2 fistulas have functioned for 4 1/2 to 15 1/2 months but have not as yet been utilized for dialysis, and 1 patient died suddenly shortly after the fistula was created. The advantages of the internal fistula for pediatric patients was the absence of infection, rarity of clotting episodes and freedom of arm movement. Despite the lack of complications and the advantages of the subcutaneous A‐V fistula in comparison with the external cannula, general acceptance was not uniform in the younger children because of the requirement for repeated venipunctures.