Exercise performance testing in patients with pectus excavatum before and after Nuss procedure.

PURPOSE: To assess the changes in lung function and exercise performance due to minimal invasive pectus repair. METHODS: Fifty-nine patients with an average age of 16 years were included in this prospective investigation. After determination of body mass index (BMI) and body fat patients were subjected to pre-OP, post-OP and post-implant removal spirometry and bicycle ergospirometry. Forced vital capacity (FVC), performance capacity (PC) and relative oxygen uptake were determined. RESULTS: Post-OP FVC significantly decreased from 91% of normal value to 79%, but again increased to 88% after implant removal. PC showed a significant reduction (105-97% of normal value). Likewise, the relative oxygen uptake showed a significant decrease (43.8-42.2 ml/kg per min). These findings correlated to a significant increase of BMI and body fat. When calculating oxygen uptake per kilogram lean body weight, there were no significant changes (49.8 to 49.8 ml/kg per min). CONCLUSIONS: Pectus repair resulted in a temporary reduction of FVC, which resolved after implant removal. The drop in oxygen uptake and PC could be related to a significant increase of BMI and body fat. According to our data pectus repair is not followed by improvements in lung function and exercise performance.

Pleural and pericardial morbidity after minimal access repair of pectus excavatum.

PURPOSE: The aim of this study was to evaluate the pleural and pericardial morbidity in patients that had undergone pectus excavatum corrections using minimal access repair of pectus excavatum (MARPE) at a single center. MATERIALS AND METHODS: Data from patients after MARPE from 2000 to 2007 were prospectively collected. Patients with pneumothorax and pleural and pericardial effusions were identified. RESULTS: One hundred eighty patients were corrected by MARPE. Eighty-four were identified to have pleural or pericardial morbidities. Pneumothorax was documented in 33 patients and five required placement of a chest tube. Pleural effusions were recorded in 53 and were found to recur in four patients. Drainage was necessary in 18 patients. Pericardial effusions were observed in five patients; in two cases, they were associated with recurring pleural effusions, suggesting postcardiomyotomy syndrome. CONCLUSIONS: MARPE is associated with a high rate of pleural and pericardial morbidities, but only a small number requires interventions.

Intramedullary nailing for the treatment of dislocated pediatric radial neck fractures.

INTRODUCTION: Pediatric radial neck fractures represent 5-10% of all elbow fractures. Open reduction allows anatomic fracture fixation but compromises the vulnerable blood supply of the radial head. Intramedullary nailing combines the advantages of closed reduction and stable internal fracture fixation. MATERIAL AND METHODS: During a 6-year-period the medical records of all children sustaining a radial neck fracture treated operatively at our institution were analyzed retrospectively. RESULTS: Forty-two patients with dislocated fractures of the radial neck were treated with intramedullary nailing. The average age of the patients was 8 years. Thirty-eight patients (90%) could be treated with closed fracture reduction and retrograde nailing. Open fracture reduction was required in 4 (10%) patients, and in 2 patients necrosis of the radial head occurred. Loss of reduction was seen in 7 (17%) patients. Excellent results were found in 38 patients, good results in 2 patients, and poor results in another 2. CONCLUSION: The retrograde nailing technique for the treatment of dislocated fractures of the radial neck in pediatric patients is a simple, short and safe procedure.

Pediatric ovarian tumors--dilemmas in diagnosis and management.

BACKGROUND: Ovarian tumors are rare in the pediatric age group and thus diagnostic and treatment strategies are heterogeneous. This study aims to evaluate ovarian tumors with a focus on age at presentation, imaging characteristics, diagnostic strategy, tumor presentation and management. METHODS: Data was collected retrospectively from patients admitted between 1991 and 2008 for the evaluation and therapy of ovarian tumors. RESULTS: Twenty-five patients were identified with neoplastic ovarian lesions (mean age 10.7 years). Sixteen patients (64%) underwent surgery for benign and 9 (36%) for malignant tumors. Benign tumors (n=16) had a mean diameter of 10.7 cm and mean age at presentation was 9.6 years compared to a diameter of 18.6 cm and 12.3 years in the malignant group (n=9). Elevated tumor markers were observed in 3 (12.5%) benign tumors and in 7 (77.8%) malignant tumors. In preoperative ultrasound investigation, cyst formation was identified in 4 benign tumors and solid tumor mass in 2 malignant tumors. A minimally invasive surgical approach was chosen in two patients, while open surgery was opted for in the rest. CONCLUSION: Cyst formation, small tumor size and younger age at presentation were characteristic of benign tumors. Malignant tumors often presented with elevated tumor markers, a larger size and a solid consistency. Diagnostic dilemmas remain for both tumor groups due to the different tumor types and the heterogeneity of presentation.

Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication.

AIM: To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS: From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS: Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION: Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.

Does epilepsy influence the outcome of antireflux procedures in neurologically impaired children?

In neurologically impaired patients (NIP), surgical management of gastroesophageal reflux disease (GERD) has become a widespread standard. Several follow-up studies have shown a high incidence of complications and recurrent reflux. As one of the possible causes epilepsy is mentioned repeatedly in the literature. The aim of this study was to determine the effective impact of epilepsy on the postoperative outcome by comparing results of our patients suffering from epilepsy to those without this disorder. From 1984 to 1999, a total of 45 NIP underwent antireflux surgery, including 20 patients suffering from epilepsy (EP) and 25 patients without this disorder (nEP). The existence of epileptic disorders, incidence of epileptic seizures and administration of anticonvulsatory drugs as well as results of diagnostic procedures, postoperative complications and incidence and time of recurrence of pathologic GER were recorded and analysed retrospectively. Preoperatively all patients had pathologic results in 24 h pH-monitoring. Median RI was 15.75 (EP, range 5.2-28.6) and 17.55 (nEP; range 7.2-26.5). 12-months-postoperative 24 h pH-monitoring showed a median RI of 3.8 (EP; range 1.3-25.6) versus a median RI of 3.3 (nEP; range 0.7-26.3). During the long-term follow-up evaluation of 3.9 years, 17 EP suffered from persistent epileptic seizures despite medical treatment. 19 patients (42%) developed recurrent reflux. This included seven EP (35%) and 12 nEP (48%). The necessity of reoperation was higher in nEP (n = 5, 20%) than in EP (n = 1, 5%). This analysis did not show a significant correlation between recurrence of pathologic GER after fundoplication and the incidence of epileptic seizures. We consider our findings to strongly question the widespread opinion considering this correlation. We conclude, that cerebral seizures alone do not alter the operative outcome of antireflux surgery in NIP.

Paralytic ileus in a fetus-neonate after maternal intake of benzodiazepine.

Paralytic ileus of the small bowel was diagnosed in a fetus at 32 weeks' gestation after referral because of polyhydramnios. The mother had taken clonazepam, a benzodiazepine, and carbamazepine during the entire pregnancy for epilepsy. All known causes for the ileus were ruled out and at 20 months the boy has developed normally. We conclude that maternal anticonvulsant drug intake was very likely the cause of the paralytic ileus. This side-effect is known in experimental and clinical pharmacology but has not yet been described in human fetuses.