Resection of residual mediastinal germ cell masses with the Cavitron ultrasonic surgical aspirator.

Residual mediastinal masses after chemotherapy for germ cell tumors should be resected. Complete excision of bulky residual masses may sometimes be difficult because of problems with exposure in the region of the great vessels and important nerves. Two cases are presented in which the Cavitron ultrasonic surgical aspirator (Valleylab Inc., Surgical Systems Division, Stamford, Conn.) facilitated excision of large masses after intensive chemotherapy. We found that the collapsed pseudocapsule remaining after aspiration of tumor mass allowed early improved exposure and safer dissection from neighboring vessels and neural structures. Complete excisions were accomplished and no viable tumor was found, so that the patients were spared the immediate need for further therapy. Both had uneventful recoveries.

Occurrence of frequent complex arrhythmias detected by ambulatory monitoring: findings in an apparently healthy asymptomatic elderly population.

In order to delineate the frequency of arrhythmias and conduction abnormalities in a group of apparently healthy elderly people, 24-hour ambulatory ECG recordings were obtained on subjects recruited from the Veterans Administration Voluntary Service. Their ages ranged from 60--84 (average 69). It is concluded from this preliminary study that complex supraventricular and ventricular arrhythmias occur in an apparently healthy elderly population. These findings must be taken into account in assessing the clinical significance of arrhythmias in an elderly population.

Ultrasonic resection of neuroblastomas. Long-term local tumor control.

OBJECTIVE: To evaluate the effectiveness of ultrasonic aspiration in achieving local tumor control of bulky neutroblastomas that are considered unresectable by conventional means. DESIGN: A retrospective review of 12 patients undergoing ultrasonic aspiration as part of multimodal treatment protocols. SETTING: A pediatric oncology referral center. PATIENTS: Twelve children with large neuroblastomas located in the abdomen (n = 5), chest (n = 5), and neck (n = 2). Follow-up was 1.5 to 7.5 years. INTERVENTIONS: Ultrasonic aspiration of the tumor was primary therapy (n = 7) or followed initial chemotherapy (n = 5). All patients underwent subsequent chemotherapy or autologous bone marrow transplantation. MAIN OUTCOME MEASURES: The incidences of residual disease and local recurrence were examined. RESULTS: Tumor-related symptoms were effectively relieved in all 12 patients. Recurrent local disease led to death in two. One patient died of distant metastases. CONCLUSIONS: Ultrasonic aspiration minimized blood loss and did not cause damage to adjacent organs. It provided nearly complete tumor resection, enhanced the effectiveness of chemotherapy protocols, and decreased the need for supportive care. Ultrasonic aspiration is a safe and effective method for obtaining local control of large neuroblastomas.

Effect of ophthalmic metipranolol and timolol on exerise-induced tachycardia.

PURPOSE: We compared the systemic beta-adrenoceptor blockade elicited by metipranolol with timolol in a randomized, double-masked, multiple crossover study in 24 healthy volunteers. METHODS: On each of 4 test days, subjects exercised on a treadmill for 10 min at 4 mi/h at a 5% gradient. After a 30-min rest, they received one drop OU of either 0.1 or 0.3% metipranolol HCI, 0.5% timolol maleate, or an artificial tear vehicle. RESULTS: With 10 min of exercise, mean heart rate increased from +/-80 to 140 beats/min preinstillation. During the postinstillation exercise, mean heart rate increased to a maximum of 141.5 +/- 19.6, 141.8 +/- 17.2, 139.7 +/- 19.7, and 131.5 +/- 16.9 beats/min in the vehicle, 0.1% metipranolol, 0.3% metipranolol, and 0.5% timolol groups, respectively. Pairwise comparisons at this time revealed a significant difference between timolol and each of the other treatments. CONCLUSIONS: Given the ocular hypotensive equivalency of various concentrations of metipranolol to timolol in other studies, it appears that metipranolol may have an improved therapeutic index relative to timolol.

Diagnosis and treatment of respiratory symptoms of initially unsuspected gastroesophageal reflux in infants.

Gastroesophageal reflux (GER) in infants is most commonly thought of as repeated excessive vomiting and failure to thrive, with most infants responding favorably to medical therapy. However, GER may also manifest exclusively with a variety of respiratory symptoms that, if not detected and treated early, may lead to life-threatening complications. During the period of 1987 to 1992, 39 neonates and infants underwent Nissen fundoplication for the treatment of respiratory symptoms attributed to GER. Symptoms included apnea and bradycardia (64%), pneumonia (31%), cyanosis (28%), cough (18%), and stridor (15%). Most patients were ascribed at least one incorrect diagnosis to explain respiratory symptoms. These include apnea of prematurity (38%), bronchopulmonary dysplasia (31%), asthma (8%), and subglottic stenosis (8%). All patients underwent a variety of investigations and medical treatments without noticeable clinical improvement. These included bronchoscopy, esophagoscopy, and polysomnograms. Treatment such as antibiotics, theophylline, bronchodilators, steroids, and oxygen were directed at presumed primary respiratory disease. On the other hand, H2 blockers, metoclopramide, positioning, and thickened feeds were prescribed to treat GER without objective evidence of disease. Ultimately, GER was demonstrated by upper gastrointestinal series in 64%, pH probe in 61%, and both studies in 38%. All patients underwent Nissen fundoplication after failed attempts at medical therapy. A total of 95% of patients had resolution or substantial improvement of respiratory symptoms postoperatively. Preoperative hospitalization averaged 37.0 days, and postoperative stay averaged only 14.2 days. We present a series of patients with GER, all of whom presented with respiratory symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative treatment of gastroesophageal reflux in low birth weight infants.

Operative correction of symptomatic gastroesophageal reflux (GER) has been used frequently and successfully in both children and larger infants for many years. In contrast, surgical repair of GER has been applied relatively sparingly in very small infants because of perceived technical and postoperative difficulties. We retrospectively reviewed our experience with Nissen fundoplications performed for symptomatic GER in low birth weight (LBW) infants ( < or = 2500 grams the time of surgery). Twenty-one consecutive cases from 1988 to 1993 were evaluated. At the time of surgery, the average age was 9.1 weeks and the average weight was 2100 grams (range, 1220 to 2500 grams). All infants had failed a trial of medical management. Follow-up from 1 month to 5 years showed no intraoperative complications and resolution of symptoms in 91 per cent of our patients. Technical factors found to enhance the success of the operative repairs included appropriately sized dilators, division of the short gastric vessels, and a loose 360-degree wrap. With suitable technique, the surgical management of symptomatic GER can be performed safely in small infants.

Simultaneous correction of malrotation and gastroesophageal reflux in infants.

Gastroesophageal reflux (GER) is often associated with gastrointestinal malrotation in infants. Primary correction of the malrotation, reserving a secondary antireflux procedure for those patients with persistent symptoms of GER, is most commonly practiced. This decision is based on the notion that an antireflux procedure may be unnecessary and is associated with added morbidity. We retrospectively reviewed 12 infants with GER and malrotation. All infants had symptoms attributed to GER and/or malrotation. A control group of seven infants with malrotation only was included for comparison of operative duration and postoperative recovery. Infants who received concurrent Ladd and Nissen procedures (Group 1, n=8) had immediate resolution of symptoms. Infants treated by Ladd procedure alone (Group 2, n=4), had persistent symptoms, despite postoperative medical therapy. A subsequent antireflux procedure was necessary. Comparison of operative times showed that a simultaneous procedure added, on average, 35 minutes to the Ladd procedure. Postoperative feeding and hospital stay were comparable between Group 1 and the control group. In contrast, Group 2 patients had longer hospitalizations due to ineffective medical therapy for persistent GER. No significant morbidity was noted. We recommend comprehensive surgical treatment with concurrent Ladd and Nissen procedures. This approach provides expedient and effective treatment of GER and malrotation, with minimal increase in operative time and no increase in morbidity .

A comparison of laparoscopic versus open splenectomy in children.

Laparoscopic operative procedures are gaining wider acceptance in pediatric patients. Although laparoscopic splenectomy is being performed more frequently, no studies to date have compared this procedure with the standard open technique with respect to operative outcomes. We performed a case control study of seven laparoscopic splenectomies and 14 open splenectomies. Two-tailed t test was used to compare the two groups for mean operative time, mean hospital stay, mean interval before tolerating a regular diet, and total parenteral narcotic dose in morphine equivalents. Operative time was significantly longer in the laparoscopic group (221 minutes vs 59 minutes, P < 0.001). Hospital stay, interval before tolerating a regular diet, and postoperative narcotic dose did not differ significantly between the two groups. In the laparoscopic group, one operation was converted to an open procedure secondary to bleeding complications. Three patients required mini-laparotomies for removal of extremely large spleens after completion of the dissection. Pediatric laparoscopic splenectomy does not appear to have advantages over the traditional method with regard to operative time, hospital stay, postoperative ileus, or postoperative pain. Larger studies, including cost analysis, are needed before major proposed advantages of laparoscopic splenectomy can be accepted.

Alternative method for repair of the difficult infant hernia.

BACKGROUND: Inguinal hernia repair in the small infant is often technically difficult. An alternative operative approach has been developed that can simplify troublesome repairs, while decreasing the potential risks of damage to cord structures and of recurrence. METHODS: Thirteen small infants (weight 1400-3000 grams) underwent inguinal hernia repair using a technique of direct closure of the internal inguinal ring via a trans-hernial sac approach. Dissection of cord structures from the sac was avoided. RESULTS: All hernia repairs remained intact on follow-up of 4-28 months. One patient early in the series developed a noncommunicating hydrocele, prompting the addition of sac eversion to the original technique. CONCLUSIONS: An alternative method for simplified repair of difficult infant hernias has been used with success. While it does not supplant traditional repair technique for most patients, it should be considered for use in selected situations.

Long-term follow-up of patients treated with ileoendorectal pull-through and right colon onlay patch for total colonic aganglionosis.

BACKGROUND/PURPOSE: This study was performed to assess the long-term follow-up of five patients who underwent one-stage ileoendorectal pull-through with right colon onlay patch for total colonic aganglionosis (TCA) at Kaiser Permanente Medical Center. METHODS: A retrospective review of inpatient and outpatient charts and telephone follow-up of all patients were conducted to obtain current data regarding growth, development, bowel function, and postoperative and late complications. RESULTS: Follow-up has ranged from 2 to 11 years. All patients are at or above the 50th percentile for weight by age and are continent with 1 to 5 daily bowel movements. Only two patients required reoperation. A perirectal abscess developed in one patient 2 months postoperatively. In the second patient a functional obstruction was relieved by sphincterotomy. CONCLUSIONS: Ileoendorectal pull-through with right colon onlay patch is associated with few early and late postoperative complications; it appears to be superior to other procedures in the early postoperative period because of the more rapid return to acceptable stooling patterns. This method of reconstruction provides an excellent opportunity for normal growth, development, and long-term bowel function.

Perforated pseudomembranous colitis in the breast-fed infant.

Pseudomembranous colitis (PMC) is uncommon in the infant and complications requiring surgical intervention are rare. All prior cases have involved the direct administration of antibiotics to the child. A 2-month-old girl required bowel resection for perforation of a thickened and inflamed left colon. Findings were consistent with PMC and the stool was Clostridium difficile toxin positive. The patient was treated with vancomycin and did well. The patient's mother later admitted to self-administration of ciprofloxacin while breast-feeding her infant. Oral doses of this drug are concentrated in breast milk at levels higher than serum. Antibiotics derived from breast milk can cause complicated PMC in the infant. A directed history can establish an early diagnosis and help distinguish PMC from other more common infantile enterocolitides.

Pericardial flap aortopexy for tracheomalacia.

Tracheomalacia is frequently associated with esophageal atresia and vascular compression of the thoracic viscera. Suture aortopexy, as first described by Gross, has become the most commonly used surgical procedure for alleviating the symptoms of tracheomalacia. External stenting, implantation of cartilage graft, and tracheal resection have been tried in severe cases not amenable to aortopexy. A standard aortopexy was attempted in an infant who had undergone division of the posterior portion of a double aortic arch. Because of very tight posterior attachments of the mediastinal structures, the aortic arch could not be brought up to the sternum without undue tension. A 3 x 2 cm flap of pericardium was formed, based at the aortic root. The free end was then sutured to the undersurface of the sternum, thereby pulling the aorta toward the sternum under gentle, controlled tension. The patient was easily extubated and has remained symptom free. Pericardial flap aortopexy is a relatively simple procedure with minimal risk to the aorta or trachea. It may be the preferred initial procedure in the surgical management of tracheomalacia.

The posterior sagittal approach for reconstruction of severe rectovaginal injuries.

Reconstruction of major perineal lacerations in the small child is difficult and frequently results in less-than-satisfactory continence. A 2 1/2-year-old girl who had sustained a fourth-degree perineal laceration at 9 months of age presented with a common rectovaginal orifice and complete fecal incontinence. Repair was carried out via a posterior sagittal approach, resulting in a normal-appearing perineum with complete continence. The techniques used in the posterior sagittal approach allow precise identification of the striated muscle complex and, therefore, offer a valuable means of achieving complete continence. Although the technique was originally described for reconstruction of congenital anomalies, this report demonstrates it to also be useful for reconstruction of severe perineal trauma.

An effective self-retaining retractor for anorectal procedures.

A self-retaining retractor technique is described for anorectal surgery eliminating many of the problems inherent in the commonly used instruments. It is particularly useful in endorectal pull-through procedures in which the exact level of anastomosis within the anorectal canal is of great importance.

Hemodynamic and ventilatory effects of abdominal CO2 insufflation at various pressures in the young swine.

Laparoscopic procedures requiring abdominal CO2 insufflation are applied with increasing frequency to the pediatric age group. Whereas the physiological effects accompanying insufflation have been studied in laboratory and clinical adult subjects, little is known of these effects in the juvenile subject. Young swine (weight, 10 to 12 kg, approximate age, 6 weeks) were subjected to abdominal CO2 insufflation at 10 and 15-mm Hg insufflation pressures (IP) to evaluate potential metabolic and hemodynamic effects. After intubation, minute ventilation was adjusted to obtain a baseline PCO2 between 38 and 42 mm Hg, and was kept constant during the subsequent study period. Four subjects underwent a total of eight trials, with insufflation periods of 1 hour each. Serial measurements of peak ventilatory pressure, tidal volume, end tidal CO2, arterial pH, PCO2, PO2, right atrial (RA), and inferior vena caval (IVC) pressure were obtained. Mean pH decreased from 7.45 +/- 0.03 to 7.22 +/- 0.03 at 10 mm Hg IP, and from 7.44 +/- 0.01 to 7.19 +/- 0.03 at 15 mm Hg IP. Mean PCO2 increased from 39.9 +/- 0.4 to 70.0 +/- 1.0 mm Hg at 10 mm Hg IP, and from 39.9 +/- 0.5 to 76.8 +/- 1.6 mm Hg at 15 mm Hg IP. PO2 decreased by approximately 37% at both IPs. End-tidal CO2 increased by 53% at 10 mm Hg IP, and by 68% at 15 mm Hg IP. Right atrial pressure did not increase significantly, and IVC pressure increased in proportion to the IP. Abdominal CO2 insufflation in this model produced marked acidemia, hypercapnia, decreased oxygenation, and increased exhaled CO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal expansion as a bridging technique in stage IV-S neuroblastoma with massive hepatomegaly.

Stage IV-S neuroblastoma has a relatively favorable outcome. However, urgent surgical treatment may be necessary for management of life-threatening complications related to massive hepatomegaly caused by metastatic tumor infiltration. The enlarged liver often becomes of primary concern because diaphragmatic elevation results in life-threatening respiratory embarrassment. An external SILAS-TIC dome has been used as a temporizing procedure to decrease the intraabdominal pressure. The authors developed a modification of this approach using an internal polytetrafluoroethylene patch to create a ventral hernia. This technique decreases the potential complications of prosthetic material use, namely, risk of infection. The graft may be left in place for an extended period and removed in staged operations as the bulk of the metastatic tumor regresses.

Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates.

Nine very low birth weight (VLBW) neonates (< 1,000 g) undergoing abdominal exploration for peritonitis were found to have focal perforations of the gastrointestinal (GI) tract and no clinical or histologic evidence of necrotizing enterocolitis (NEC) or other mechanical cause. Although most patients presented initially with clinical findings suggestive of NEC, none developed the traditional clinical or radiographic findings associated with this diagnosis. Most patients initially had normal bowel gas patterns or transient bowel distension on abdominal x-ray, followed within hours by a paucity of bowel gas or a totally gasless abdomen. Paracentesis was positive in 7 patients. A blue, purplish, or dusky discoloration of the abdomen was described in 7 patients prior to surgery. Surgery was performed at an average age of 16.7 days. In all, the bowel appeared grossly normal with the exception of a 0.3- to 1-cm focal perforation of the small intestine or colon. One patient had an additional similar perforation of the stomach. Treatment in most was simple exteriorization of the perforation. The one gastric perforation was oversewn. Biopsy specimens at the site of perforation from 4 patients were described as having focal necrosis without intrinsic bowel disease. Two were noted to have Candida invading the bowel wall. Unlike the typical bowel flora found on culture in infants with perforations due to NEC, these patients had cultures and histological specimens positive for Candida and/or Staphylococcus epidermidis. We conclude that focal GI perforations occurring in the VLBW infant represent a clinically distinct phenomenon and that the traditionally accepted diagnostic criteria for bowel perforation due to NEC are unreliable in this condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Resection of advanced stage neuroblastoma with the cavitron ultrasonic surgical aspirator.

Current protocols for the treatment of neuroblastoma emphasize total or near total resection of tumor to improve survival. This is preferentially performed as a primary procedure, or is attempted at a second-look operation. Unfortunately, this tumor often grows to large size with invasion of the spinal canal, or encasement of major vascular or other retroperitoneal structures. A primary attempt at complete removal may result in difficult-to-control hemorrhage or injury to, or loss of, vital organs. A second-look procedure carries other intrinsic risks. It often must be performed during a period of chemotherapeutically induced hematologic and immunologic suppression. The presence of adhesions and dense scar tissue increases the complexity of the dissection. The Cavitron Ultrasonic Surgical Aspirator (CUSA) combines continuous fragmentation, irrigation, and aspiration in one instrument. Tissues high in water content are selectively fragmented and aspirated, while tissues high in collagen and elastin (such as blood vessels and pseudocapsular walls) are selectively spared. Five patients, two with large pelvic dumbell tumors, two with large intrathoracic tumors, and one with a seemingly unresectable large right adrenal tumor (crossing the midline with extensive aortocaval nodal involvement) had total or near-total resection accomplished using the CUSA. In these patients, initial resection of the relatively soft inner part of the tumor left a collapsed pseudocapsule, which was then removed under greatly improved exposure in a relatively small field. The constant aspiration virtually eliminated tumor spillage. Since most vessels were skeletonized without penetration, total blood loss was minimized. There were no intraoperative or postoperative complications.

Malignant presacral teratoma in children.

Malignant presacral teratoma is a rare tumor seen predominantly in young female children. The introduction of planned multidisciplinary treatment has improved the outlook for patients with this once dismal disease. Six female children were seen at Memorial Hospital with the diagnosis of malignant presacral teratoma. Five children were age 17 mo to 3 yr and the sixth child was 13 yr old at diagnosis. Presenting symptoms included masses in the buttock or groin, constipation, difficulty voiding, and local pain. Pathological features were varied and complex but three had predominantly endodermal sinus features. One child had the malignant presacral teratoma develop 18 mo after successful resection of a benign sacrosoccygeal teratoma in the newborn period. Treatment varied in the six cases since all were referred after failure of treatment elsewhere. All children had surgery, irradiation, and multiple drug chemotherapy. Four of the six children are surviving disease-free, 3 more than 24 mo off treatment. Evolution of treatment up to the present protocol management is discussed.

Condyloma acuminata: an unusual presentation of child abuse.

Condyloma acuminata seen in childhood is a disease not well recognized as a sign of child abuse. These viral lesions are often diagnosed and treated without regard to their venereal mode of transmission. Four infants and children with condyloma acuminata ranging in age from 14 mo to 11 yr required surgical management. Two required multiple procedures for control of the lesions. Indications for surgical treatment include large, recurrent, or refractory lesions, as well as the need for histologic identification and acquiring tissue for immunotherapy when necessary. The follow-up care is often difficult because of the socioeconomic structure of the involved families. Careful and persistent medical and social care is necessary to adequately treat the disease and remove the source of infection and to protect children from sexual abuse.