Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first?

Major hepatic vein and retrohepatic vena caval injuries are often fatal because of massive uncontrollable hemorrhage. Children with these injuries can be identified by their unique and dramatic clinical presentation and the selective use of computed tomographic imaging. Volume resuscitation promotes abdominal wall tamponade and hemodynamic stability until the abdomen is opened, at which point there may be sudden exsanguination before vascular control can be obtained. An alternative approach is to open the sternum before opening the abdomen. Management in this sequence provides rapid vascular control and improves the efficiency of hepatic exclusion. To date, five children with major hepatic vascular injuries have been treated with the sternotomy-first approach and four have survived; an atriocaval shunt was used on two occasions. Although sternotomy before laparotomy improves the efficiency of hepatic exclusion and may offer improved survival, accurate preoperative case selection limits its routine use.

The pediatric trauma center.

The types of facilities providing care to injured children vary greatly. Some have organized, planned, and functioning Pediatric Trauma Units with all the appropriate personnel, equipment, and facilities needed to provide whatever is needed. Other institutions have done no planning, have no trained personnel, and are, in short, ill prepared to provide any type of care. The resources needed to provide optimum care to the injured child are described for two types of facilities--the Regional Pediatric Trauma Center (RPTC), which provides the most comprehensive of pediatric trauma services, and the Trauma Center with Pediatric Commitment (TCPC), which is the type of institution at which the majority of pediatric trauma care is rendered.

Congenital microgastria in a premature infant.

The authors report the case of a 1,500-g baby boy with microgastria, vascular ring, tracheoesophageal fistula (TEF), and the VATER association. Despite repair of the TEF and placement of a gastrostomy tube, he failed to thrive and had recurrent bouts of aspiration pneumonia. Gastric augmentation at 8 months of age resolved the feeding problems, and he now has a normal diet.

Blunt bile duct injuries in children.

Three of 87 children with blunt liver injuries initially managed without operation required late intervention for bile leakage. Abdominal computed tomography scans in these patients showed liver injuries extending into the porta hepatis. Clinical courses were characterized by persistent abdominal pain, low-grade fever, and prolonged ileus. Radionucleide scan confirmed the suspicion of bile leakage. One patient had complete transection of the common bile duct, which was repaired surgically. Another had partial transection of the left hepatic duct, managed successfully with transampullary biliary decompression. The third patient with an intrahepatic injury was managed with a drain placed at celiotomy. Nonoperative management of blunt pediatric liver injuries carries a risk of persistent bile leakage. Radionucleide scan and endoscopic retrograde cholangiopancreatography are reliable modes of diagnosis and localization. Transampullary biliary decompression is a newer, effective modality for management of the proximal and/or partial bile duct injuries. Treatment must be individualized according to the site and extent of injury.

TNP-470 inhibits intraabdominal adhesion formation.

BACKGROUND/PURPOSE: Angiogenesis plays an integral role in wound healing and tissue remodeling. The authors hypothesized that inhibition of angiogenesis would reduce intraabdominal adhesion formation. METHODS: In 98 C57BL6/J mice, a 2-cm midline laparotomy was performed and a 5 mm2 SILASTIC (Dow Corning, Midland, MI) patch fixed to the right side of the peritoneum. Mice were injected with normal saline (n = 54) or TNP-470, an inhibitor of angiogenesis (n = 44; 30 mg/kg every other day over 6 days before surgery until 10 days after surgery). Animals were killed on postoperative days 10, 15, 35, and 55. Adhesions to the SILASTIC (Dow Corning) patch were scored based on their extent, type, and tenacity. Angiogenesis was quantified digitally as the area of vascularized peritoneum over the patch. RESULTS: At day 10, when TNP-470 was stopped, the percentage of vascularized peritoneum over the patch was less in treatment animals than in controls (P = .004). At day 35, the patch in treatment animals was completely covered by vascularized peritoneum, similar to controls. Adhesions in TNP-470 animals were reduced at day 10 compared with controls (P<.05) and remained reduced off treatment at day 55. CONCLUSIONS: Angiogenesis appears to play an important role in the development of intraabdominal adhesions, because the extent of early neovascularization correlates with adhesion formation. Perioperative treatment with TNP-470, a potent endothelial cell inhibitor, reduced vessel ingrowth over the patch and was associated with a sustained reduction in adhesion formation.

Carotid artery reconstruction following neonatal extracorporeal membrane oxygenation.

Although reconstruction of the right common carotid artery (RCCA) in neonatal extracorporeal membrane oxygenation (ECMO) patients is intuitively attractive, there is little known about prolonged arterial cannulation and how it may affect subsequent vascular repair. A histological study of RCCA segments from neonatal ECMO patients was performed, so that cannulation technique and catheter design could be optimized before proceeding with arterial reconstruction. Circumferential transmural necrosis (CTN) was found in 25 of 31 (80%) arteriotomy specimens in comparison with 2 of 9 (20%) more proximal carotid specimens; the remaining specimens in each group demonstrated either focal subintimal or focal transmural necrosis. CTN was more common in patients with longer ECMO runs (96 +/- 5.9 versus 75 +/- 5.6 hours, P = .009; arteriotomy site), but was independent of cannula size, birthweight, and gestational age. Eleven patients have undergone RCCA reconstruction. Doppler flow studies at 4 to 7 months of follow-up in five patients demonstrated slightly higher right-sided versus left-sided peak systolic, end-diastolic, and mean flow velocities. No neurological or developmental problems could be attributed to vascular reconstruction. In conclusion, RCCA reconstruction is technically feasible, but due to the high prevalence of CTN at the arteriotomy site, excision of this segment is recommended at the time of arterial repair.

Operative intervention for pediatric liver injuries: avoiding delay in treatment.

To identify the physiological and anatomic factors that characterize the need for operative management of blunt pediatric liver injuries, the case records of 106 pediatric trauma victims with liver injuries over a 6-year period were reviewed. Sixty-nine patients were managed without operation (nonoperative) and 37 underwent operation, 7 with penetrating and 30 with blunt liver injuries. Of these 30 patients, 21 underwent laparotomy due to blunt liver injuries (operative); the remaining 9 patients required operation due to associated intraabdominal injuries. Nine (45%) of the 21 operative patients had major hepatic vein or retrohepatic vena caval injuries, 7 of whom died. Overall mortality was 9.4% (10/106). When nonoperative and operative groups were compared, those who underwent laparotomy due to blunt liver injuries: (1) had significantly lower Champion and Pediatric Trauma Scores due to multisystem injury; (2) had 25% or greater lobar disruption with pelvic blood collections on computed tomography scan; (3) underwent early transfusion within 2 hours of admission (18/21); and (4) were frequently found to have a major hepatic vein or retrohepatic vena caval injury at the time of operation. Only one patient successfully managed without operation received greater than 30 mL/kg of blood products within 24 hours of admission. As selective nonoperative management of pediatric liver injuries gains widespread acceptance, the identification of factors that predict the need for operative intervention will limit the potential risks of delay in treatment.

Early management of the child with multiple injuries.

Resuscitation of the child with multiple injuries is similar to that for adults, except that instrumentation and therapy must be tailored in accordance with variable patient size, emotional maturity, and injury response. Because this response is rapid and often compensatory, there is greater reliance on noninvasive means to diagnose and manage the injured child. Children who suffer multisystem trauma typically present with head injury, followed in decreasing frequency by limb fracture and trauma to the torso. The timing of fracture fixation in a patient with multiple injuries remains controversial. In general, clinical judgment will determine the optimal timing for fracture reduction or operative fracture fixation. Management of an associated vascular injury must take into consideration the mechanism of injury, tissue viability, vessel size, and technical limitations. With appropriate initial resuscitation, careful monitoring, and sound clinical judgement, most injured children can be expected to have a good clinical outcome.

Use of umbilical vessels for neonatal ECMO cannulation: possibilities and precautions.

Extracorporeal membrane oxygenation (ECMO) is being employed with increasing frequency for the treatment of neonates with severe cardiac or respiratory failure. The risks related both to carotid artery and jugular vein ligation continue to cause concern. Use of umbilical vessels for vascular access in ECMO could eliminate many of these risks. The experience to date with this approach is summarized, along with case reports of three patients treated at our center in whom the umbilical vein was cannulated to augment venous drainage. One patient died of causes unrelated to umbilical vein cannulation. One had an uneventful ECMO course and is a normal survivor, and one developed a tension hemopericardium as a complication of the umbilical vein cannulation, but is a normal survivor. Potential risks and benefits of this approach are reviewed.

Congenital pulmonary alveolar proteinosis: failure of treatment with extracorporeal life support.

Pulmonary alveolar proteinosis, a rare disease in neonates, is characterized by the accumulation of insoluble amorphous material within the alveoli. We describe two pairs of siblings with pulmonary alveolar proteinosis in two otherwise unaffected families. All four patients were term neonates in whom severe pulmonary failure developed within hours after birth; three had mature lung profiles. Radiographic lung markings were characterized by an early granular pattern followed by lung opacification. All patients were treated with extracorporeal life support for periods of 212 to 381 hours, but none survived. Life spans ranged from 16 to 190 days. We speculate that pulmonary alveolar proteinosis in neonates results from a genetic defect in surfactant processing that may not be amenable to conventional or unconventional therapies, including extracorporeal life support.

Internal carotid artery blood flow velocities before, during, and after extracorporeal membrane oxygenation.

Blood flow velocities in the internal carotid arteries were studied with pulsed Doppler in 25 neonatal patients (birth weight range, 2600 to 4100 g) who had extracorporeal membrane oxygenation (ECMO). Time averaged mean systolic, mean diastolic, and mean blood flow velocities were calculated. Five infants had right common carotid artery reconstruction. Blood flow velocities measured in 15 healthy full-term infants were used as controls. Findings during ECMO included the following: (1) forward flow in the right internal carotid artery in 50% of the infants; (2) significant increase in the mean diastolic and the mean flow velocities (48% and 128%, respectively) in the left internal carotid artery when compared with pre-ECMO and control infants' values; (3) the elevation in the mean and the mean diastolic velocities was associated with changes in the PaCO2 and with an increase in the diastolic blood pressure; and (4) forward blood velocities in the right internal carotid artery were comparable with blood velocities in the left internal carotid artery and with the blood velocities of control infants. After ECMO, the mean diastolic velocity in the left internal carotid artery decreased significantly, but it remained elevated when compared with pre-ECMO values. Infants with right common carotid reconstruction had blood velocities in the right internal carotid artery comparable with the simultaneous blood velocities in the left internal carotid artery and to the blood velocities of control infants. Twenty-eight percent of the infants had major neuroanatomic lesions. Right or left preponderance was not noted. No association between blood velocity values in the internal carotid arteries or flow direction and the presence or the absence of brain lesions was noted.