Effects of PEEP on cardiovascular dynamics after open-heart surgery: a new postoperative monitoring technique.

The circulatory effects of incremental increases in positive end-expiratory pressure ventilation (PEEP) were assessed on 11 occasions in post-operative cardiac surgical patients by phasic aortic blood flow measurements and high-fidelity pressure recordings from which flow and pressure-flow derivatives of cardiac performance were calculated. At 15 cm H2O PEEP, mean arterial blood pressure was decreased by 10%, stroke volume and cardiac output by 15%, and peak left ventricular power by 21%. Although these indices promptly returned to control levels when PEEP was discontinued, levels of PEEP above 10 cm H2O should be used with caution for this group of patients.

A monitor for the continuous assessment of left ventricular performance after open-heart operations.

A cardiac monitoring system has been developed that incorporated phasic aortic blood flow measurement by an extractable electromagnetic flow probe and high-fidelity arterial blood pressure recordings. Cardiac output, stroke volume, and peak aortic blood flow are measured continuously; using logarithmic amplifiers, the pressure-flow derivatives of left ventricular function, such as cardiac power and stroke work, are obtained beat by beat. This monitor is used to follow the postoperative course of patients undergoing cardiac operations and to evaluate the hemodynamic effect of therapeutic agents.

The long term effect of intra-aortic balloon counterpulsation on left ventricular performance.

A patient who had had two coronary artery bypass grafts and an aneurysmectomy required intra-aortic balloon pump (IABP) assistance to allow discontinuation of cardiopulmonary bypass (CPBP). An indwelling electromagnetic flow probe on the ascending aorta was used to monitor IABP over the following 8 days of assistance. Stroke volume (SV), Cardiac output (CO), stroke work (SW), and ventricular afterload (VA) were measured directly. Recovery was indicated as the discrepancy between CO and SV on and off IABP decreased. VA depended upon the degree of augmentation. SW bore an incostant relationship to IABP.

[Ambulatory pediatric surgery--possibilities and limits]. / Ambulante Kinderchirurgie--Möglichkeiten und Grenzen.

Pediatric surgical operations performed on an ambulatory basis in a practice are still rare in Germany. Prerequisites, indications, possibilities and limitations are presented. Some 869 operations were performed under general anesthesia within 21 months. Of the children 70% were under 5 years of age. The postoperative results were evaluated by means of a questionnaire in 352 children. Early complications occurred in five instances (1.4%) and late complications in one child (0.3%); hernia recurrence). Observing the possibilities and limitations, ambulatory pediatric surgery yields good results and takes the peculiarities of children into consideration.

[A case of ruptured congenital neuroblastoma caused by birth injury]. / Ein Fall von geburtstraumatisch rupturiertem, kongenitalem Neuroblastom.

A 3,900 g full-term male newborn had to be operated on for suspected intraabdominal bleeding due to birth injury. Intraoperatively, a tennis-ball sized, ruptured tumor between right kidney and liver was found to be the source hemorrhage. The tumor was excised in toto. The newborn died 25 hours after the end of operation from protracted shock and renal failure. Post mortem examination did not reveal further malformations or metastases. Histological diagnosis: congenital neuroblastoma of the adrenal gland. Improved antenatal ultrasound diagnosis followed by cesarian section could help to improve the prognosis in such cases in future.

Hypospadias--genetics, epidemiology and other possible aetiological influences.

Questionnaires relating to 515 children with hypospadias were evaluated in respect of course of pregnancy, family history and epidemiology. The domiciles were more often in rural areas as compared to the average population in South Bavaria. A seasonal trend favouring the six months' period December to May could be observed. Children with hypospadias especially of higher degree were more often preterm and more frequently firstborn. 59 children (11.5%) had associated malformations particularly of the urogenital tract. Mothers of children with high-degree hypospadias were remarkably young and conspicuously often wives of farmers. There was a clear correlation between the degree of hypospadias and threatened abortion, drugs, sexhormones and other disturbances during early pregnancy. The trend to lower age classes could be also observed in fathers. The incidence of hypospadias in fathers was 5-fold and in brothers 30-fold above average. The risk of recurrence was 1.4% if the father had a hypospadia and 6% if a brother had hypospadias. The incidence of other malformations did not seem to be enhanced in relatives.

Historical aspects of hydrocephalus.

From early days on physicians took interest in hydrocephaly because of its grotesque appearance. Already Hippocrates recommended decompression-trepanation for the treatment of hydrocephalus. Only since anatomy and pathophysiology of hydrocephalus as well as production and absorption of the cerebrospinal fluid was clarified, more effective operative techniques could be developed. Conservative treatment was unsuccessful or was useful only as temporary or adjuvant therapy supporting surgical procedures. A great variety of operative methods was described since the middle of 19th century which yielded, however, unsatisfactory results in most instances. Results improved since the introduction of effective valve systems in combination with ventriculoatrial and ventriculoperitoneal shunts. Despite of improved results, the treatment of hydrocephalus remains problematic as is shown by the still high complication rate and the restless search for more effective ways of treatment.

[Operative procedure in choledochal cysts (author's transl)]. / Beitrag zum operativen Vorgehen bei Choledochuszysten.

Case-description of a large cyst of the bile duct in a 10-year-old girl. The cyst extended from the distal part of the common hepatic duct almost to the duodenum. The pancreatic and bile ducts drained the cyst distally with a common outlet. The cyst was resected, except for a small preduodenal remnant. The remaining part was closed to form a hood, and implanted end-to-side into a loop of small bowel which had been diverted by Roux's method. The common hepatic duct was also anastomosed end-to-side with the same diverted loop of bowel.

Course of pregnancy, family history and genetics in children with spina bifida.

Course of pregnancy, family history and genetics were evaluated in 257 children with spina bifida and compared with 537 non-malformed controls investigated under the same criteria. Birth data exhibited a significant seasonality with a maximum in January and a minimum in July which differed from the average distribution of birth data in Bavaria (maximum April, minimum October). The total number of pregnancy disturbances was 60.6% in mothers of spina bifida children, whereas this figure amounted to 30.1% in mothers of the control group. This high incidence of pregnancy disturbances in spina bifida was due to a high rate of diseases (6 times above controls) and drugs (6 times above controls) during early pregnancy. In 22.9% of children with spina bifida malformed relatives were found, whereas this was the case in only 6.4% of the children of the non-malformed control group. Not only malformations of the central nervous system but also malformations of other organ systems were found to be increased in relatives. This is a pointer not only to genetic influences as well-known aetiological factor, but also towards a generally higher susceptibility to malformation genesis in a relatively small group of persons. Risk of recurrence was 0.5% if one parent was affected and 4% if a sibling was affected.

Catamnestic investigations in children with congenital hydrocephalus.

Catamnestic investigations on the course of pregnancy, family history and genetics were carried out in 141 children suffering from congenital hydrocephalus. The results were compared with those obtained from a group of non-malformed controls investigated by the same criteria. There was a considerably higher incidence of pregnancy disturbances (i.e. diseases, drugs, haemorrhage etc.) in mothers who later gave birth to a child with congenital hydrocephalus, than mothers of the control group (congenital hydrocephalus: 61.3% vs. controls: 30.1%). This high incidence of pregnancy disturbances could be particularly referred to a sevenfold increased rate of diseases and a fourfold increased rate of drug intake during the first trimester. There was also a higher rate of malformed relatives in children with congenital hydrocephalus (16.7%) than in controls (6.4%); not only were malformations of the central nervous system found to be increased but also malformations of other organ systems in relatives. This is interpreted as a hint not only at genetic influences but also at a generally higher incidence of malformations in a relatively small group of persons. Calculated figures of recurrence risk were in accordance with empirical data used in genetic counselling.

Haemostasis in injuries of parenchymatous organs by infrared contact coagulation.

A series of 11 children aged from 1 day to 12 years is reported in which infrared contact coagulation with a sapphire coagulator was used for haemostasis in liver and splenic injuries. Seven children were cured. The four deaths were not related to the injuries of parenchymatous organs. Infrared contact coagulation is a suitable and cheap method for organ preservation in injuries or other pathological conditions of parenchymatous organs in childhood.

Progress in the diagnosis of gastroesophageal reflux in childhood: 24-hour pH monitoring.

Twenty-four-hour pH monitoring is a reliable and secure method for use in the diagnosis of gastroesophageal reflux (GER). Compared with other methods, this technique is well tolerated and without complications. In contrast to other techniques (cineradiography, manometry, scintiscanning, endoscopy), long-term pH monitoring is the only method to measure the dynamics in the distal esophagus under nearly physiological conditions and to register the data obtained via pen writer for any time desired. Thus, 24-h pH monitoring is the most sensitive and expressive method for the diagnosis of GER in childhood, providing more secure operative indications combined with other methods.

Surgery for benign and malignant diseases of the thyroid gland in childhood.

From 1970 to 1986, 51 children and adolescents aged 5-18 years were operated on for diseases of the thyroid gland, among them 42 with benign diseases (juvenile goiter 21, adenoma 17, Graves' disease 3, Hashimoto's thyroiditis 1) and nine with malignancies (papillary carcinoma 4, follicular carcinoma 3, medullary carcinoma 1, anaplastic carcinoma 1). In benign entities, females were three times as often affected as males, whereas both sexes were equally affected in malignancies. Positive family histories were found in 23.3% of the children with adenomas in 71.4% of the children with juvenile goiters. Subtotal strumectomy was carried out in 30 instances and enucleation in 12. Iodized salt and L-thyroxine were given postoperatively as recurrence prophylaxis. Recurrence was seen in two children (4.8%) who had no recurrence prophylaxis. Symptoms in children with malignancies were palpable cervical lymph nodes and solitary nodes in the thyroid gland. Total thyroidectomy was done in all instances, followed by radio-iodine treatment in eight cases and cobalt 60 irradiation in one case. Two children died, of diffuse metastases and irradiation fibrosis of the lung respectively. The peculiarities of diseases of the thyroid gland in childhood that require surgery are discussed.

Resection of an intrathoracic tracheal stenosis in a child.

A 6-year-old boy sustained a severe head injury during a traffic accident. He was first treated at another hospital. Despite a short intubation period of only 3 days, within 4 weeks he developed severe tracheal stenosis, with a residual lumen 3 mm in diameter and a total length of 2.3 cm, ending 3 cm above the carina. After initial bougienage enlarging the lumen to 6 mm in diameter, surgery was performed at our hospital 6 weeks after the accident. The stenosis was resected in toto, and tracheal continuity was restored by interrupted sutures using the Grillo technique. The postoperative course was uneventful. Follow-up tracheoscopy 3 months later showed a residual stenosis of 20% within the anastomotic region, and the patient was free of symptoms.

[Postoperative course in children with malignant tumors following preoperative chemotherapy]. / Postoperativer Verlauf bei Kindern mit malignen Tumoren nach präoperativer Chemotherapie.

Postoperative course is reported in 52 children with malignant tumors (neuroblastoma, Wilms-tumor, non-Hodgkin-lymphoma, osteosarcoma etc.) who were operated on between 1979 and 1987. 26 children received chemotherapy prior to surgery, whereas 26 children were operated on without preceding chemotherapy (control group). Most children were under six years of age. 15 Children (57.7%) with preoperative chemotherapy developed early postoperative complications, such as sepsis, pneumonia, suture dehiscence, woundhealing disturbances and ileus, whereas this was the case in only 5 children (19.2%) without preoperative chemotherapy (P 0.0005). Four of the children with preoperative chemotherapy (15.4%) sustained late complications, such as local recurrence or mechanical bowel obstruction, whereas none of the control children did so. Lethality rate from underlying disease did not differ in both groups during follow-up (5 = 19.2% vs. 5 = 19.2%). This demonstrates that the surgeon must carefully be aware of an increased possibility of early and late complications in children who have to undergo surgery for malignant tumors following preoperative chemotherapy.

Infrared-contact coagulation of parenchymatous organs - report of three cases.

Infrared-contact coagulation of the spleen with an infrared-sapphire-coagulator was applied in two children with subcapsular hematoma and splenic cyst, thereby achieving complete and partial organ preservation, respectively. This method was also used for haemostasis following the dissection of a common liver in Siamese twins. Infrared-contact coagulation is a proper method for organ preservation in injuries or other pathological conditions of parenchymatous organs.