[Evaluation of 5 years of experimental in utero surgery for the repair of diaphragmatic hernia]. / Bilan de cinq années de chirurgie expérimentale in utero pour la réparation des hernies diaphragmatiques.

The incidence of diaphragmatic hernia in he newborn is 1:2,500 to 5,000 births. An extensive American programme of foetal surgery for in utero repair of this defect has shown that the pulmonary hypoplasia was due to compression of lung tissue by the herniated organs. This process could be interrupted be repairing the diaphragmatic defect early enough in utero (before the 28th week). The results of five years of experimental surgery for in utero correction of diaphragmatic hernia are presented here. The experimental model used was the Macaca fascicularis monkey, the pregnant female of which having several gestational and endocrine characteristics similar to those of the pregnant woman. Three different experimental programmes were carried out successively. A first series including five animals was used to experiment both surgical and anaesthetic techniques; three foetuses died in utero. The second series (10 animals) was designed to find a suitable protocol for tocolysis. One female died after surgery, and seven other foetuses also died. The third group (13 animals) was the main study group. The diaphragmatic hernia was first created surgically, and then repaired. No foetus died from the surgery. One female died before giving birth, and one offspring died shortly after birth as its mother had no milk. After the encouraging results obtained with this last series of animals, the procedure was applied to human cases, with the Hospital Ethical Committee's approval. In the first case, the foetus died postoperatively as a result of the rupture of the diaphragmatic prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Autotransfusion using Cell Saver III. Experience with 90 cases of surgery of the spine in childhood and adolescence]. / Autotransfusion par Cell Saver III. Expérience de 90 cas de chirurgie du rachis chez l'enfant et l'adolescent.

Intra-operative transfusion was used with Cell Saver Haemonetics III in 90 children undergoing spinal surgery for scoliosis. This technic keeps pace with controlled bleeding by collecting and processing shed blood and reinfusing washed packed red cells. During high blood loss procedures this device allowed to save up 51% of shed red cells. Our study of the intra-operative bleeding and its replacement was assessed with calculation using an individual regression line for each patient. Statistical analysis was performed by using multivariate correlation and "step wise analysis".

[Better acceptance of measures for induction of anesthesia after rectal premedication with midazolam in children. Comparison of results of an open and placebo-controlled study]. / Bessere Akzeptanz der Massnahmen zur Einleitung einer Narkose nach rektaler Prämedikation mit Midazolam bei Kindern. Vergleich der Ergebnisse einer offenen und einer Plazebo-kontrollierten Studie.

The rectal administration of midazolam for premedication of children before induction of anesthesia by mask was investigated in two clinical studies. In 62 children aged between 2 and 10 years, midazolam was given by open design at various dosages (0.15 mg.kg-1, 0.25 mg.kg-1, 0.30 mg.kg-1, 0.35 mg.kg-1, 0.40 mg.kg-1) to evaluate the most effective dose for optimal acceptance of the mask and gas mixture. An additional 40 children between 3 and 9 years received 0.2 mg midazolam.kg-1 body weight or placebo in a double-blind design to estimate the lower limit of efficacy of midazolam. All children were classified as ASA I and had to undergo a surgical procedure. Within the two studies the children were not different with respect to their general data, age, weight, and sex. In both studies more boys than girls were included. Parameters of efficacy were the degree of sedation before and at 10, 20, and 30 min after midazolam as well as acceptance of the mask and the gas mixture at induction of anesthesia. In all groups, including placebo, a sedative and tranquilizing effect of the premedication was found. The rectal administration of 0.35-0.4 mg midazolam.kg-1 is most suitable for the preoperative medication of children between 2 and 10 years. Due to the degree of sedation and the relief of anxiety toward the surroundings and the operation, the induction of anesthesia is optimally accepted by the child. In contrast, the effect of a dose around 0.2 mg midazolam.kg-1 body weight is not much different from that of placebo and is not sufficient for effective premedication.

[In utero surgery of diaphragmatic hernia in Macaca fascicularis]. / Chirurgie in utero de la hernie diaphragmatique chez le singe macaque (Macaca fascicularis).

The aim of this study is to be able to perform on the animal (Macacus cynomolgus) a specific in utero surgical procedure for correcting congenital diaphragmatic hernia, in order to do the same on human fetuses. The surgical technique consist in operating in utero, and to put a silastic patch on the diaphragm. A good tocolysis is very necessary to prevent early abortion. Finally the fetuses' surviving is the main problem.

[Continuous peridural anesthesia in children less than 2 years old]. / Anesthésie péridurale continue chez l'enfant de moins de deux ans.

Continuous epidural anaesthesia was carried out in 23 children (age 13.9 +/- 6 months, weight 9.09 +/- 2.5 kg) scheduled for long surgical procedure (soft tissue release for club-foot, "pull-through" for Hirschsprung disease, various genito-urinary procedures). The lumbar epidural space was punctured under general anaesthesia with a 19 G Tuohy needle. A graduated 24 G polyurethane catheter was then inserted and fixed. The local anaesthetic used was bupivacaine 0.25% (0.71 +/- 0.02 ml X kg-1), with or without 1:200,000 adrenaline. Five and 10 min after injection of bupivacaine, heart rate was significantly decreased (p less than 0.05) when compared with pre-induction values, but systolic blood pressure did not change. No other haemodynamic changes occurred. Analgesia was sufficient in all but two cases at incision. Mean duration of surgical procedure was 143 +/- 9.2 min. The time of the first reinjection was significantly longer if bupivacaine with adrenaline was used (116 +/- 2.34 min), when compared with bupivacaine without adrenaline (68.9 +/- 3.92 min) (p less than 0.001). No systemic analgesic was needed during the surgical procedure and anaesthesia was maintained either with halothane (inspiratory fraction less than 0.5%) or enflurane (inspiratory fraction less than 0.8%). All children were extubated at the end of the surgical procedure. The catheter was maintained in 16 children for postoperative analgesia. The first postoperative injection was given 7.1 +/- 0.45 h later. The catheter remained in situ 26.7 +/- 4.1 h. No complication was observed. Thus, during surgery, the need for systemic analgesia was avoided and a rapid and safe postoperative recovery was obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anesthesia of the newborn weighing less than 2000 g, 100 cases (author's transl)]. / Anesthésie de l'enfant de moins de 2 000 g. Cent cas.

We gave special attention to these very fragile newborns in whom associated pathology was often present. We were faced above all by respiratory and hemodynamic problems. Pre-operative care is essential and must be adapted to the degree of emergency. The newborn must reach the operating room in normothermia, normoxia and in adequate metabolic status. The anaesthesia technique used was always simple with few anaesthesics and ventilation controlled manually and mechanically after intubation. Scrupulous monitoring was always the case. Principal anaesthesic incidents included hypothermia and tachycardia. A precise cause was linked to the 13 accidents encountered. In 8 cases slow decurarisation was noted. Special comments must be made about the premature infant's possibilities versus pharmacocinetic of anesthesics, hemodynamic modification, hyperbi lirubinemia hepatic and renal enzymatic immaturity. Thus we think the anesthesiologist must be specifically trained for the care of these patients.

[Esophageal atresia and gastro-esophageal reflux]. / Atrésie de l'oesophage et reflux gastro-oesophagien.

Gastro-esophageal reflux has been noted in 60% out of 113 cases of esophageal atresia treated successfully at the Hôpital Saint-Vincent-de-Paul, between the years 1970 and 1978. The tolerance of the reflux in these 58 cases has been variable : 13 children developed severe respiratory complications; 17 children had a stricture at the anastomosis site. Although the general outcome for this type of reflux should be favorable, either spontaneously or by medical means, surgical treatment, usually by fundoplication occasionally may be indicated; 15 children were operated. One died from reflux complications before the operation could be planned. It is possible that the severity of the reflux may be related to the extensive dissection and the tension needed to achieve approximation of the two esophageal segments during repair of the atresia. Some aggravation factors leading to respiratory complications, such as tracheomalacia, and tracheal compression by innominate artery would be an indication for an early anti-reflux operation.

[Compressive brachio-cephalic arterial trunk and gastro-oesophageal reflux following surgery for oesophageal atresia (author's transl)]. / Troni artériel brachio-céphalique compressif et reflux gastro-oesophagien dans les suites opératoires d'atrésie de l'oesophage.

6 cases of cardiorespiratory complications occurring after surgical treatment of oesophageal atresia are reported by virtue of the association of tracheal compression by the brachio-cephalic arterial trunk and of gastro-oesophageal reflux. In all cases, medical (2 cases) or surgical (4 cases) treatment of gastro-oesophageal reflux led to the disappearance of all respiratory symptoms and signs. Emphasis is placed upon the need for a routine and thorough search, radiological and endoscopic, of such associated oesophageal pathology, before proceeding to surgery on the compressive brachio-cephalic arterial trunk.