Hepatectomy in children under total hepatic occlusion.

Major ablative hepatic resection is often indicated in children with solid liver tumors, and reduction of operative blood transfusion is a primary goal. Total hepatic occlusion (THO) is an effective method that is well established in adults, yet its role in children is less well described. We describe our preliminary experience with THO in children assessing surgical outcome. The charts of seven children (ages 5 months to 7 years, weight 6-30 kg) who underwent THO during hepatectomy (four right and three left lobectomies) for liver tumors (hepatoblastoma in three, metastatic Wilm's tumor in two, mesenchymal hamartoma in one, and angiosarcoma in one) between January 1997 and June 2002 were reviewed. THO was established in all cases by clamping the supra- and infrahepatic inferior vena cava and the porta hepatis. Surgical parameters assessed included: 1) warm ischemia time, 2) operative blood transfusion, 3) operative complications, and 4) tumor resection margins. THO was successful in six of the seven cases (85.7%). In one case systemic hypotension unresponsive to fluid resuscitation developed at the outset with THO requiring conversion to pedicle clamping to perform the hepatectomy. Mean warm ischemia time during THO was 26 minutes (range 18-45 minutes). Mean estimated blood loss was 221 cm3 (range 50-800 cm3). Operative blood transfusion was required in one of six patients (15 cm3/kg). Excluding the "failed" THO case (intraoperative hypotension) there were no significant intraoperative or postoperative complications. All seven children had curative resections as indicated by "tumor-free" microscopic margins. We conclude that total hepatic occlusion can be performed safely and successfully for pediatric liver tumors. Operative blood transfusion appears to be minimized.

Primary insertion of a silastic spring-loaded silo for gastroschisis.

Gastroschisis is traditionally managed by emergency primary closure, with a temporary silo reserved for large defects unable to be closed primarily. We recently have begun primary Silastic (Dow Coming, Midland, MI) spring-loaded silo (SLS) closure followed by elective closure and report our preliminary experience. A total of 15 infants (weight range, 2.1-13.5 kg) at 2 different institutions were treated by SC by 3 different surgeons between 1998 and 2002. A 3-, 4-, or 5-cm (ring diameter) silo was used depending on size of abdominal wall defect. Elective closure was performed in the operating room or at the bedside. Surgical parameters assessed included success of SLS, peak inspiratory pressures (PIPs) pre- and post-SLS closure, total time of staged closure with SLS, time to full feedings, and intra- and postoperative complications. Fifteen of 15 infants were successfully treated by SLS closure followed by elective closure. Two of 15 (13.3%) experienced temporary dislodgement of the silo prior to permanent closure. In both cases, the silo was safely reinserted at the bedside. Comparison of PIP values measured at various stages of SLS closure revealed no significant difference (P > 0.05). Mean times to final fascial closure (3.7 days) and full enteral feedings (22 days) were similar to historical controls obtained from the surgical literature. In 1 case where there was associated intestinal atresia, SLS closure was effective in permitting concomitant elective closure and re-establishment of bowel continuity. All children are alive and well at the time of this report. SLS closure permits safe, gentle, and gradual reduction of the exposed viscera leading to successful permanent abdominal wall closure. Respiratory embarrassment and hemodynamic instability associated with emergent (primary) closure of large abdominal wall defects can thus be avoided.