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.

Rupture of the duodenum with avulsion of the papilla of Vater due to blunt trauma in a child, and review of the literature.

Duodenal rupture with avulsion of the papilla of Vater is an uncommon injury due to blunt abdominal trauma in children. This report describes a 9-year-old boy who sustained this injury and was treated successfully two days delayed by a Roux-en-Y choledocho-pancreaticojejunostomy and temporary implantation of a zipper for abdominal wall closure. The rarity of this complex injury and its initial presentation as a posttraumatic pancreatitis warrant its description. A review of the literature, modes of diagnosis and surgical technique for repair are described.

Morbidity and mortality of the short-bowel syndrome.

From 1976 to 1998 we have treated 17 neonates with short-bowel syndrome. Those 8 patients who had an intact ileocecal valve as well as the total colon preserved did significantly better than the 9 children without ileocecal valve and > 50% missing colon. In addition to the length of the intestinal remnants, motility had a major impact on the incidence of complications and final outcome. Four patients died (23.5%). All of them had an intestinal length of less than 30 cm, severe dysmotility, no ileocecal valve and an incomplete colon. The average duration of hospitalization of the children weaned from parenteral nutrition (n = 11) was 8.5 months. The majority of them still need supplementation of vitamins and/or trace elements. Two children suffer from recurrent d-lactic acidemia. Six children have a significant psychomotor developmental delay with three suffering from congenital cerebral abnormalities.

Congenital short-bowel; a case study and review of the literature.

A congenital short bowel (CSB) is a rare entity in pediatric surgery. We present the case of a newborn boy with a total small intestinal length of 47 cm, malrotation and gastroesophageal reflux, who is 19 months old at the time of this report. Main treatment steps were Ladd's procedure, a fundoplication and long-term parenteral nutrition. We suggest that missing physiological herniation of the gut into the coelomic cavity may impair normal intestinal growth and rotation and lead to congenital short bowel. Review of all cases reported in the literature shows a considerable mortality of 88%. The limiting factor seems to be reduced motility of the short small bowel causing functional obstruction and liver failure.

[Automated exchange transfusion in premature and newborn infants with hyperbilirubinemia using a peripheral arteriovenous vascular access device]. / Automatisierte Austauschtransfusion bei Früh- und Neugeborenen mit Hyperbilirubinämie unter Verwendung eines peripheren arteriovenösen Gefässzuganges.

The technique of exchange transfusion using a plastic catheter in the umbilical vein developed by Diamond and modified by Allen was instrumental in decreasing the mortality and morbidity in newborn infants with jaundice. Allen et al. demonstrated that the development of kernicterus in infants with erythroblastosis with indirect hyperbilirubinemia could be prevented by this method. Since that time numerous modifications of this "single site, push pull technique" have been described to further reduce the risk of morbidity and mortality. On the basis of the successful use of percutaneous radial artery catheters for arterial blood gas monitoring, we developed a technique for exchange transfusion using a peripheral arterial catheter inserted in the radial artery for blood withdrawal and a peripheral venous catheter for replacement of heparinized compatible donor blood. For simultaneous withdrawal and replacement we used two volumetric infusion pumps, one aspirating patients' arterial blood, the other replacing equal volumes of donor blood at exactly the same time. We evaluated our new procedure in 19 newborn infants (group 1) with hyperbilirubinemia who required exchange transfusion. Retrospectively we analysed the data in 18 newborn infants (group 2) treated over a previous period by means of the conventional "one site, push pull" technique using the umbilical vein, and compared the data. Mean birth weights, gestational ages and Apgar scores were similar in both groups, as were volumes of blood used for exchange transfusions. The results were superior in group 1 infants, as reflected by the significantly greater percentage decreases in serum bilirubin concentration and fewer complications. No baby died.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous cannulation of the radial artery in severely ill premature and newborn infants]. / Perkutane Kanülierung der Arteria radialis bei schwerkranken Früh- und Neugeborenen.

Cannulation of the radial artery is an easy and safe alternative to the usual procedure of catheterization of the umbilical artery to secure blood for gas sampling and for monitoring blood pressure in critically ill neonates. The use of a fiberoptic light source further improves the success of percutaneous radial artery cannulation. We performed this procedure in 264 critically ill babies and it was successful in 211 (80%). The average weight was 2.160 g (740-4,300), gestational age was 33 weeks (26-45). The radial artery catheter had an average useful life of 5 days (1-22). In 53 newborn infants the catheter had to be removed prematurely because obtaining blood samples was no longer possible. In 15 babies the catheter had to be removed on account of arterial spasms. One patient developed skin necrosis of a small area on the tip of the thumb due to a thrombo-embolic complication. No case of bacterial infection due to cannulation was observed. No neurological disturbance in hand or finger function was found on follow up after one year. In conclusion, this method is safe, easy to handle, has less complications and several advantages over previous methods.

[Ingestion of caustic substances in childhood]. / Ingestion von ätzenden Substanzen im Kindesalter.

Patients who ingest caustic substances continue to pose difficult problems in diagnosis and management. Flexible fiberoptic endoscopy and radiological studies have helped to assess the extent of damage caused by corrosives. A number of non surgical techniques are available for therapy, mainly corticosteroids and antibiotics. In a retrospective study from January 1976 till October 1988 we analysed 86 children aged from 1 month to 11 years. The purpose of our analysis was to check the outcome in patients with corrosive burning treated by standardized therapeutic management. Alkaline household substances caused the injury in 75% of our patients. No lesions were found in 19 patients. There were 21 patients with first degree, 28 with second degree ans 18 with third degree lesions. The diagnosis was confirmed by endoscopy within the first 48 hours. Therapeutic management in 2nd and 3rd degree lesions was based on corticosteroids, antibiotics and early bougienage of the oesophagus over an endless thread. Three patients with 2nd degree and all 18 patients with 3rd degree lesions underwent bougienage. Corticosteroids were given for two to four weeks, depending on the severity of the lesion. Our results demonstrate that early diagnosis and therapy can help to reduce stenosis and prolonged illness of these patients. In addition, public health efforts should be made to educate people about the dangers of caustic substances.

Risk factors and severity indices in necrotizing enterocolitis.

In retrospective analysis we set up a chart review of 61 consecutively newborn infants with proven diagnosis of necrotizing enterocolitis. The 26 female and 35 male infants were admitted to the intensive care unit of the Department of Pediatric Surgery from 1985 to 1991. Birth weights varied from 790 to 4680 g (mean value 2408 +/- 853), gestational ages from 27 to 43 weeks (mean value 36 +/- 4.0); 33 patients received conservative treatment and 28 patients were operated on. An analysis of operated (group 1) and conservatively (group 2) treated patients revealed no statistically significant difference in birth weight, gestational age, peripartal complications or type of feeding. Yet a few parameters measured at admission remained as severity indices. Operated babies had significantly higher counts of immature granulocytes and an elevation in the I:T-ratio, as well as lower counts of total granulocytes, lymphocytes, platelets and lower weights of the placenta. However, when taking into account the gestational age, the results showed that these parameters became insignificant in the low birthweight group below 34 weeks, and were of higher validity in the gestational age group over 35 weeks. In the latter group, C-reactive protein also proved to be a good parameter with statistical significance respecting the severity of necrotizing enterocolitis.

Problems of ileostomy in necrotizing enterocolitis.

Exteriorization of the intestine and resection of the gangrenous bowel are major therapeutic regimens for necrotizing enterocolitis (NEC). Ileostomy associated complications are well known, therefore the time of ileostomy closure is a matter for discussion. Between 1975 and 1992, 84 patients with NEC were treated surgically. Ileostomies were performed in 37 children (44%). Of these 37 neonates, 9 (7M, 2F) died. In the remaining 28 patients (16M, 12F) with a mean gestational age of 35.8 weeks and a mean birth weight of 2412 g, ileostomies were performed between the 2nd and 11th days after birth. On average, the stomies were in function for 91 days, and within this period the average weekly weight gain was 153 g. Nineteen patients of this group did not show any problems attributable to the ileostomy. In 9 patients (32%) complications occurred, requiring a preplanned closure of the stoma. Postinflammatory strictures of bowel were diagnosed in 9 patients and resection of the stenotic intestine was performed at the same time as stoma closure. In conclusion, an appropriate weight gain can be achieved in patients with an ileostomy with an adequate feeding regimen. In otherwise uncomplicated cases, ileostomy closure can be delayed by up to 10 weeks when simultaneous surgical correction of additional intestinal strictures is possible. In one-third of patients with an ileostomy, however, complications may occur and urge a preplanned closure of the stoma.

[Sports and physical training in childhood--general principles]. / Sport und Training im Kindesalter--Allgemeine Grundlagen.

Whether functional performance of children in response to exercise adapts in a similar way to that of adults and exactly what the influence of growth and maturation is in determining a child's performance has not been completely resolved. Regarding to respiratory factors the younger the child the higher the pulmonary ventilation per liter of oxygen consumption. Girls tend to have a higher ventilatory volume in exercise than boys and after puberty it is significantly lower in boys than in girls. Maximal oxygen consumption increases with age in both sexes as a consequence of increased size but aerobic capacity in children is more related to size and body composition than age. Regarding to cardiovascular factors aerobic capacity is largely determined by maximum cardiac output which itself is dependent upon stroke volume and rate of heart beat, because young children have smaller hearts, they have higher heart rates to compensate for the smaller stroke volume compared with adults. Children have higher maximum heart rates than adults, ranging from approximately 195-220 beats/minute. After maturity there is a decrease in heart rate with age of approximately 0.8 beats/min/year of age. Because of the larger hearts greater stroke volumes and an increased blood volume after puberty males have a higher resting systolic blood pressure than females.(ABSTRACT TRUNCATED AT 250 WORDS)

[Traumatic embolization of the middle cerebral artery]. / Traumatische Embolisierung der Arteria cerebri media.

A 3 mm metallic particle, which had blasted during grinding operation, shot into the neck of a nine year old boy, penetrated into the common carotid artery and embolized the right middle cerebral artery. There had been no neurological symptoms until four days after the injury. Suddenly, a mild left side hemiparesis occurred with accentuation of the arm. The case illustrates an unusual penetration and intravascular migration of a foreign body. After the injury, penetration and subsequent peripheric embolisation can happen immediately, or as in our case within a short time after. Hence, the small particle may not be detected by a local radiogram, or may not be found on surgical exploration. Therefore, in all cases of neck wounds caused by low velocity injection of foreign bodies, radiological evaluation with skull-x-rays and a neurological examination should be done. If further special scans are required, these should be accomplished by axial computer tomography, because the metallic nature of the foreign bodies would prohibit the examination by magnetic resonance.

[Stress adapted parenteral amino acid substitution in operated premature and newborn infants]. / Stressadaptierte parenterale Aminosäurensubstitution bei operierten Früh- und Neugeborenen.

Parenteral nutrition contributes considerably to the survival of operated newborns. The postoperative period, however, gives rise to special metabolic problems. Commercially available L-amino acid (L-AA) solutions may lead to imbalances in the postoperative period. We used a preparation containing all essential and non essential L-AA, which should take the stress metabolism into account. Twenty newborn infants were treated with a standardized parenteral nutrition regime after major surgery. Two comparable groups were formed; the first (A) receiving up to 2 g L-AA/kg/day and the second (B) 1.5 g L-AA/kg/day at the most. On the seventh postoperative day group B was loaded with 1 g L-AA/kg within 6 h corresponding to the transfer rate in healthy newborn infants calculated by Bürger and Wolf. Plasma L-AA were checked on the seventh day before and after loading. The serum L-AA showed almost normal values in group A, however, several values were found to be too low in group B (proline, alanine, cystine, leucine). After the L-AA load some increased above normal levels (threonine, glycine, lysine, histidine). With reference to these results a daily application of 1.5-2.0 g of L-AA/kg can be recommended for critically ill newborns in the early postoperative period.

[Pulmonary agenesis in partial trisomy 2 p and 21 q]. / Lungenagenesie bei partieller Trisomie 2 p und 21 q.

A case with bilateral cheilognathopalatoschisis, and dysplastic features agenesis of the left lung is reported. Complete absence of one lung is a very rare malformation and was due to our knowledge not reported in partial trisomy 2 p or 21 q.

[Esophageal function of infants with sudden infant death--risk]. / Speiseröhrenfunktion von Säuglingen mit Sudden Infant Death--Risiko.

In 24 patients at risk for SIDS (12 infants with a near miss event and 12 infants with apnea and perioral cyanosis during sleep) respiratory and esophageal function were investigated by impedance pneumography (IP) and esophageal manometry combined with simultaneous pH-monitoring (EMPH). Both groups had ad early pathologic breathing pattern, but did not show any difference in the recorded parameters (number of apneic spells, longest apneic spell, apneic spells longer than 10 seconds, transcutaneous oxygen pressure, mean apnea time). Near miss infants had about 50% more manometric refluxes (15.4 +/- 1.3) than the apnea/cyanosis group (9.9 +/- 2.2). This difference was mainly caused by a significant rise of reflux episodes without pH-change (near miss 8.5 +/- 3.1 versus 2.9 +/- 1.4 in apnea/cyanosis infants). Furthermore, propulsive peristaltic properties after induced swallows were more disturbed in the near miss group (3.3 +/- 1.0 versus 6.1 +/- 1.9). On the other hand, the apnea cyanosis group showed significantly more pH-drops under 4 (6.8 +/- 2.3 vs 2.4 +/- 0.7), which might be due to a more rapid clearance of neutralising milk from the stomach in these infants. In conclusion the study showed that infants with a near miss event in the anamnesis suffer from a more pathologic esophageal motor function when compared with infants with apneic spells and cyanosis during sleep. Near miss infants are also considered to have a delay of gastric clearance.