A novel treatment approach to H-type esophageal lung in presence of pulmonary artery sling with pneumonectomy and intrathoracic tissue-expander placement.

Congenital tracheal anomalies occur in 1:10,000 births and can be associated with congenital cardiac disease. This patient presented with right mainstem atresia, right bronchoesophageal fistula without esophageal atresia (H-type esophageal lung), and left pulmonary arterial (PA) sling. Taking this into consideration, surgical management included right pneumonectomy and placement of expandable prosthesis into the thoracic cavity to buttress the mediastinum and prevent tracheal deviation-induced kinking of the PA sling, which provided pulmonary blood flow to the remaining functional lung. To our knowledge, this is the first reported case of esophageal lung in conjunction with a PA sling, as well as the first documented use of an expandable prosthesis to prevent acute postpneumonectomy syndrome. This case can provide clinicians with increased clinical knowledge for treatment of this rare and potentially lethal combination of congenital anomalies.

Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique?

OBJECTIVE: Video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax refractory to nonoperative management was first reported in children by Rodgers in 1986 (Ann Surg. 1986; 204:677-680). Small series have shown success with apical blebectomy, mechanical or chemical (talc) pleurodesis, or combination techniques. We report the largest pediatric series of VATS for primary spontaneous pneumothorax (PSP) to date, to assess outcomes and compare techniques. METHODS: Retrospective review of all children undergoing VATS for PSP between 1999 and 2007 at 2 university-affiliated hospitals by the same group of surgeons. Mann-Whitney U tests and chi(2) used (P < .05 = significant). RESULTS: Thirty-two patients underwent 41 VATS procedures (32 initial-30 unilateral, 2 bilateral; 9 subsequent-7 contralateral, 2 ipsilateral recurrences). Mean age at presentation was 16.5 years (range, 13-20 years). Blebs were identified at the time of VATS in 95% of patients, but in 12.5%, they were on lower lobes. Mean duration of postoperative air leak was 2.7 days, postoperative hospital length of stay was 5.0 days, and postoperative chest tube duration was 5.1 days; 2 patients required Heimlich valves, which were managed at home. Five different surgical techniques were used as follows: blebectomy plus mechanical pleurodesis had the shortest length of stay (4.3 days) and need for chest tube drainage (4.1 days) but had a higher recurrence risk (6% major, 16% minor) than blebectomy plus chemical pleurodesis. The risk of requiring an additional VATS procedure (ipsilateral or contralateral) was 28%. Mean follow-up was 46 months. CONCLUSIONS: Blebectomy plus either mechanical or chemical pleurodesis were both associated with acceptable outcomes. Blebectomy plus chemical pleurodesis appears to have less risk of ipsilateral recurrence but longer postoperative stay and chest tube drainage.

Gastroschisis, atresia, dysmotility: surgical treatment strategies for a distinct clinical entity.

PURPOSE: Intestinal atresia (IA) occurs in 10% to 20% of infants born with gastroschisis (GS). We describe a distinct subset of these children with severe dysmotility, without mechanical intestinal obstruction, and with adequate intestinal length for enteral nutrition and propose possible treatment strategies. METHODS: A total of 177 patients with GS managed at a single institution between 1993 and 2007 were retrospectively reviewed. RESULTS: Twenty-one (12%) patients had IA. Six (29%) did well, with gradual progression to full diet; 1 died at birth because of complete midgut infarction; 1 died of necrotizing enterocolitis; 4 with short bowel syndrome (SBS) (small bowel length, 30-41 cm) died of liver failure because of total parenteral nutrition (3) or sepsis (1). Nine (43%) were felt to have gastroschisis/atresia/dysmotility, defined as adequate small bowel length for survival as measured at time of laparotomy (mean, 146 cm; range, 66-233 cm), massive intestinal dilatation, and stasis. Of 9 patients with gastroschisis/atresia/dysmotility, 5 (56%) survived. All had surgery to "rescue" their dysfunction intestine, at mean age 128 days (range, 52-271 days): 4 had tapering enteroplasties of mean 37 cm (range, 5-115 cm)-all 4 survived; 3 had diverting stomas created for intestinal decompression, followed by stoma closure-1 survived; 1 nonsurvivor had a Kimura "patch"; 1 nonsurvivor underwent redo anastomosis. Survivors weaned off total parenteral nutrition at mean age 331 days after rescue surgery (range, 42-814 days). CONCLUSIONS: More than one third of patients with GS/IA appear to have significant intestinal dysmotility without true SBS nor obstruction. Successful treatment of these infants may be achieved with the use of tapering enteroplasty and/or temporary diverting stomas.

Evolution of the surgical management of neonatal ovarian cysts: laparoscopic-assisted transumbilical extracorporeal ovarian cystectomy (LATEC).

PURPOSE: Since its first detailed description in 1995, the laparoscopic management of neonatal ovarian cysts has typically required multiple incisions, specialized equipment, and advanced laparoscopic skills. After some initial frustration with neonatal laparoscopy, we developed a simplified single-incision laparoscopic-assisted transumbilical extracorporeal cystectomy (LATEC). This paper reviews our experience with this technique and compares outcomes to those of our other surgically managed neonatal ovarian cyst patients. MATERIALS AND METHODS: A retrospective record review of 20 patients treated surgically between 1992 and 2006. Student's t-tests were used for comparisons (P<0.05 was significant). RESULTS: Means were: age, 11 days; weight, 3.7 kg; and cyst diameter, 5.0 cm. Nineteen patients were diagnosed prenatally, at the mean gestational age of 33 weeks. Twelve of 20 (60%) had torsed cysts (1 bilateral). Three of 13 torsed cysts (23%) were less than 4 cm diameter (range, 2.9-3.5). Laparotomies were transverse lower abdominal incisions. Laparoscopic operations used 2 (3 patients) or 3 incisions (2 patients). LATEC involved transumbilical laparoscopy, complete cyst aspiration, and then cyst evisceration through the umbilicus for either ovarian cystectomy (simple cysts) or salpingo-oophorectomy (torsed cysts). Laparoscopic patients had similar time to feeds, length of stay, and postoperative narcotic requirements, when compared to laparotomy patients (P=nonsignificant). LATEC patients had shorter surgical times, more rapid advancement to full enteral feedings, shorter length of hospital stay, and equal ovarian preservation, when compared to laparoscopy. Cosmetic results with LATEC were outstanding. CONCLUSIONS: Both laparoscopic and "open" approaches have acceptable perioperative morbidity and rapid recovery. LATEC is a relatively simple procedure, which combines laparoscopy and traditional extracorporeal surgery, and may be successfully performed by experienced pediatric surgeons and with a single incision.

Beware of the flaming hairball--a brief review and warning.

Operating room fires are receiving increasing attention in the medical literature and in the general public. The best way to reduce these iatrogenic, sometimes devastating, events is communication and education. The authors present the case of a 14-year-old adolescent girl who had an apparent explosive event during a laparotomy for removal of a large gastric trichobezoar. This event was presumably associated with gas production under increased pressures in the gastrointestinal tract caused by an obstructive and decomposing trichobezoar. This is the first reported association between trichobezoars and potential intraoperative fire and/or injury. It is the recommendation of the authors to avoid the use of electrocautery when initially entering a portion of the gastrointestinal tract thought to contain a bezoar to avoid the potential for surgical fire or concussive tissue damage.