[Infants and toddlers behavioral and functional disorders: characteristics, mother-child interactions, alliance and outcome after a brief parents-child psychotherapy. A pilot study]. / Troubles du comportement et troubles fonctionnels du nourrisson : caractéristiques, interactions mère-enfant, alliance et évolution après une psychothérapie brève parent-enfant. Étude pilote.

OBJECTIVES: Functional and behavioral disorders are the most frequent reasons for consultation in infant psychiatry, but there are still few studies about the efficacy of parents-child psychotherapies. Functional disorders appear to be easier to treat than behavioral disorders. The aim of this study was: (1) to assess outcome after a brief psychotherapy in a population of 49 infants aged 3 to 30 months, presenting functional or behavioral disorders; (2) to compare characteristics before therapy and outcomes for children with functional disorders and with behavioral disorders, to have a better understanding of the worse outcome of children with behavioral disorders. METHODS: Two assessments were performed, one before treatment and the second a month after the end of the therapy including the infant's symptoms (Symptom Check-list), parents' anxious and depressive symptoms (Hospital Anxiety and Depression scale) and mother-infant interactions (Crittenden Experimental Index of adult-infant relationship). The therapeutic alliance was assessed by the therapist and the parents after the first consultation (Working Alliance Inventory). RESULTS: The assessments after therapy show complete or partial improvement in the child's symptoms, in the mother's anxious and depressive symptoms and in the father's anxious symptoms. During interaction, the mothers become more sensible, the number of controlling and of unresponsive mothers decrease, while the children become more cooperative and less passive. Initial characteristics and outcome are however different according to the type of the child's disorder. The children with behavioral disorders are older and present an association of several symptoms. The disorder onset is later. Their mothers are, before therapy, more anxious and depressive. The therapeutic alliance is weaker. After therapy, despite the fact that their mothers' affective state and that interactive behavior improves, the mothers are more anxious and less sensible, while the children no longer differ from the group without behavioral disorder from the point of view of opposition (assessed during mother-child interaction). CONCLUSION: Although this study is limited by the lack of a control group and the sample size, it underlines some particularities of infants and toddlers presenting behavioral disorders and the difficulties involved in their treatment. One can wonder if these characteristics are specific of the behavioral disorders or if they are the result of an older dysfunction, complicated by the developmental evolution of the child and the duration of the difficulties. The small number of cases, among the children with behavioral disorders, presenting a preexistent functional disorder, the absence of difference in the duration of the disorders, and the different disorder's onset plead in favor of the first hypothesis. The behavioral disorders often associate child psychopathology, dysfunctional parents-child-relationships and environmental factors difficult to modify with a brief therapy focused on the relationship. It would appear necessary to develop specific treatments for this population.

Predictors of outcome in infant and toddlers functional or behavioral disorders after a brief parent-infant psychotherapy.

The efficacy of parent-child psychotherapies is widely recognized today. There are, however, less data on predictive factors for outcome in infants and toddlers and their parents. The aim of this study was to highlight predictive factors for outcome after a brief psychotherapy in a population of 49 infants and toddlers aged 3-30 months presenting functional or behavioral disorders. Two assessments were performed, the first before treatment and the second a month after the end of the therapy. These assessments included an evaluation of the child's symptoms, and of depressive or anxiety symptoms in the parents. The assessments after therapy show complete or partial improvement in the child's symptoms for nearly three quarters, and a decrease in the number of anxious and depressive mothers, and also in the number of depressive fathers. Three independent factors appear as predictive of unfavorable outcome for the child: frequency and intensity of behavioral problems and fears, and the absence of the father at more than two-thirds of consultations. The outcome for the mother is associated solely with her anxiety score at the start of the therapy. This study underlines the particular difficulties involved in the treatment of infants and toddlers presenting behavioral disturbances and emotional difficulties, and the value of involving the father in treatment.

The paediatric liver transplantation program at the Université catholique de Louvain.

The Paediatric Liver Transplant Program at Saint-Luc University Clinics constitutes a substantial single centre experience, including 667 transplantations performed between March 1984 and April 2003, and the history of this program reflects the tremendous progress in this field since twenty years. Liver transplantation in children constitutes a considerable undertaking and its results depend on multiple, intermingled risk factors. An analysis of the respective impact of several surgical and immunological parameters on patient/graft outcome and allograft rejection after paediatric liver transplantation showed a significant learning curve effect as well as the respective impact of pre-transplant diagnosis on survival and of primary immunosuppression on the rejection incidence. The introduction of living related liver transplantation in 1993 not only permitted to provide access to liver replacement in as many as 74% more candidate recipients, but also resulted in better graft survival and reduced retransplantation rate. The results of a recent pilot study suggest that steroid avoidance is not harmful, and could even be beneficial for paediatric liver recipients, particularly regarding growth, and that combining tacrolimus with basiliximab (anti-CD25 chimeric monoclonal antibody) for steroid substitution appears to constitute a safe alternative in this context. The long-term issues represent the main future challenges in the field, including the possibility of a full rehabilitation through immunosuppression withdrawal and tolerance induction, the development of adolescence transplant medicine, and the risk of early atherogenesis in the adulthood.

A phase II study of ET-743/trabectedin ('Yondelis') for patients with advanced gastrointestinal stromal tumours.

Primary or secondary resistance to imatinib may occur in patients with gastrointestinal stromal tumours (GISTs) while these tumours have repeatedly been shown to be highly resistant to conventional doxorubicin- and ifosfamide-containing regimens. The investigation of new drugs is therefore warranted in GIST. A phase II study was conducted between May 1999 and November 2000 in eight centres of the EORTC STBSG group to establish the efficacy and safety of ET743 ('Yondelis') in GIST previously untreated with cytotoxic chemotherapy before the imatinib era. ET-743 was given was given at 1.5 mg/m(2) per course as a 24-h continuous intravenous infusion every 3 weeks. Twenty-eight patients were included, 16 males and 12 females. Median age was 54 years (range 25-73 years). Median performance status was 0 (range 0-1). 17 (63%), 4 (12%) and 7 (25%) patients, received 0-2, 3-5, and > or = 6 courses of ET-743, respectively. The best response was stable disease in 9 (33%) patients, and disease progression in 18 patients (67%), with a median time to disease progression and overall survival of 51 days and 589 days, respectively. The treatment was well tolerated: there were grades 3-4 neutropenia, thrombocytopenia, and transaminase increases in 13 (48%), 1 (4%) and 16 (59%) patients, respectively. There were no toxic deaths. ET-743 at this dose and schedule is not an effective treatment for advanced GIST.

Pediatric liver transplantation for biliary atresia: results of primary grafts in 328 recipients.

PURPOSE: The purpose of this study was to assess the overall results of recipients undergoing transplantation for biliary atresia (BA), according to age, surgical techniques, and transplant eras, and to identify the prognostic factors affecting outcome. METHODS: Between 1984 and 2000, 328 pediatric recipients with BA who underwent orthotopic liver transplantation (OLT) were reviewed. Median age at OLT was 1.5 years (range, 0.4-14.5 years). Kasai hepatoportoenterostomy (KHPE) had been previously performed in 285 (87%) children. Regarding surgical techniques, 125 (38%) children received a whole-liver graft, 128 (39%) received a reduced-size graft, 16 (5%) received a split-liver graft, and 59 (18%) received a living-related (LR) donor graft. RESULTS: Overall actuarial patient survivals were 87%, 83%, and 81% at 1, 5, and 10 years, respectively. One-year patient survivals in children undergoing transplantation at the different age ranges were 85% (under 1 year), 86% (1-3 years), 83% (3-6 years), 100% (6-10 years), and 100% (beyond 10 years) (not significant). One-year patient survivals for the different transplant eras were 75% (1984-1988), 85% (1989-1992), 93% (1993-1996), and 98% (1997-2000) (P=0.0001). Multivariate analysis demonstrated that pretransplant recipient weight (P=0.004), indication for OLT (P=0.083), and age at OLT (P=0.024) predicted patient survival. The type of baseline calcineurin inhibitor (tacrolimus) and the age at OLT (beyond 6 years) were significantly associated with a better graft survival. CONCLUSIONS: Best results in children undergoing transplantation beyond 6 years indicate the importance of performing a KHPE as the first therapeutic step in BA; innovative surgical techniques, particularly LR donor graft, allowed successful transplantation in infants with early failure of KHPE.

Evaluation of a 1-h exposure time to mechlorethamine in patients undergoing topical treatment.

BACKGROUND: Mechlorethamine is frequently used in the treatment of cutaneous lymphoma, but its application is limited in 30-80% of cases because of cutaneous intolerance. Reducing the concentration to avoid this side-effect has been only modestly successful. OBJECTIVES: To investigate whether a shorter application period could reduce the frequency of intolerance. METHODS: In an open prospective study in 39 patients with cutaneous T-cell lymphoma or parapsoriasis, mechlorethamine was applied according to the usual practices of the participating physicians (number of weekly applications, treatment confined to lesions or performed over the entire body) and then washed off after 1 h in all cases. RESULTS: Cutaneous intolerance was observed in 19 of 39 patients (49%). Six of these patients showed allergic contact dermatitis to mechlorethamine after a mean period of 9.3 weeks, while the other 13 developed irritant contact dermatitis after a longer period. Cutaneous intolerance did not differ significantly according to the number of applications per week or the extent of body area treated. The therapeutic response rate was 69%, and no difference in therapeutic efficacy was noted between daily and intermittent applications. CONCLUSIONS: Comparison with published studies showed no significant difference in the number of cases of cutaneous intolerance after short-term application, although their occurrence was delayed. Therapeutic response was decreased appreciably by short-term application as compared with results in the literature.

Tracheal side effects of endoscopic balloon tracheal occlusion in the fetal lamb model.

OBJECTIVE: To evaluate effects of in-utero endoluminal balloon tracheal occlusion (TO) as suggested for the treatment of Congenital Diaphragmatic Hernia (CDH) on the higher airways of a fetal lamb model. STUDY DESIGN: Fetuses from time-dated pregnant ewes underwent at 94 days (term=145 days) in-utero tracheal occlusion. In study animals an endoluminal, detachable balloon was placed by tracheoscopy. For that purpose a 1.2mm fibre-optic, semi-rigid endoscope and a medically graded latex balloon were used. In group I (n=9) lambs were delivered after 2 weeks. In group II (n=8) the tracheal occlusion was released after 2 weeks, to allow in-utero recovery until term. In positive control animals (group III; n=5) the trachea was clipped at 98 days and fetuses were harvested near term by cesarean section. A total of 17 contralateral littermates in multiple pregnancies served as negative controls. After macroscopic inspection of the trachea, sections were evaluated by light microscopy. Alterations were scored with an empirical interval score for each of the different anatomical elements in the fetal trachea (epithelium, submucosa, cartilage, pars membranacea). RESULTS: For the animal experiments in group I, all balloons were found in place and according to the pulmonary response they were obstructive. Tracheas were macroscopically dilated by the plug mainly due to elongation of the pars membranacea. The total histologic score was correlated to the increase in circumference (mean increase: 3.0mm). In nearly all cases, the tracheal epithelium at the level of the plug had lost its typical folding pattern. In 44% of cases, local epithelial defects were observed and in 33% of cases there was squamous metaplasia. A chronic inflammatory response was present in over half of the cases, sometimes with giant cell reaction. In group II (the in-utero recovery group) the total score was significantly lower than in group I, with much less prominent unfolding and absence of epithelial defects. Squamous metaplastia was still present in half of the cases; whereas inflammatory responses were less frequent. In group III the trachea expanded normally after removal of the clip. The epithelium had compacted folds, and cilia were well preserved. In two animals however, intraluminal synechia were observed. Below the level of occlusion animals of groups I and II all showed areas of unfolding, but without metaplasia or epithelial defects. CONCLUSION: Tracheal obstruction by means of endoluminal plugging has been suggested as an alternative in-utero treatment for congenital diagphragmatic hernia. The balloon causes mild epithelial changes, such as unfolding, limited epithelial defects (<25% of the exposure surface) and local inflammatory changes. These changes disappear nearly completely following in-utero unplugging during the rest of gestation. Unfolding of the epithelium is also seen in the trachea under the plug.

Congenital parenchymatous malformations of the lung.

Congenital lung malformations, primary and secondary, contribute to an important portion of pediatric thoracic surgery. One purpose of this report is to outline the close relation in terms of embryology and clinical presentation of congenital parenchymatous pulmonary malformations. In a retrospective study we also aim to evaluate our experience with the diagnosis and surgical management of congenital parenchymatous bronchopulmonary malformations and to compare our data with the literature. From January 1979 to December 1996 a series of 48 patients, 30 males (62.5%) and 18 females (37.5%), were operated on for congenital bronchopulmonary malformations. Pulmonary sequestration, bronchogenic cysts, congenital lobar emphysema, and congenital cystic adenomatoid malformation were seen in 16, 13, 5, and 14 patients, respectively. The first clinical symptoms occurred at a mean age of 8.8 years (1 day to 62 years), and the mean age at the time of surgical intervention was 9.3 years (1 day to 62 years). The maximum time between first symptoms and surgical treatment was 27 years. A lobectomy was performed in 22 cases; in the other patients more lung-preserving surgery such as enucleation or sequestrectomy was performed. Only one postoperative death occurred following lobectomy for pulmonary sequestration, and it was due to pulmonary hypoplasia and pulmonary hypertension. Eleven other patients presented with postsurgical complications: pneumothorax (n = 5), pleural effusion (n = 3), prolonged air leak (n = 2), portal vein thrombosis (n = 1), and hemorrhage requiring reintervention (n = 1). We conclude that any thoracic cystic lesion expanding on chest radiography should be an indication for surgical resection, even if asymptomatic, because of the risk of pulmonary compression, infection, or malignant degeneration. In the few cases of a fetal intrathoracic mass, prenatal diagnosis and intrauterine intervention may be indicated, and these indications are also discussed.

Time-related cotyledonary effects of laser coagulation of superficial chorionic vessels in an ovine model.

Endoscopic Nd:YAG laser coagulation of superficial chorionic plate vessels has been suggested as a 'causal' therapy for severe twin-to-twin transfusion syndrome (TTS), as it is believed to arrest flow over vascular anastomoses. The therapy remains debated, partly because it is questioned whether coagulation of superficial chorionic vessels can arrest blood flow over deeply located anastomoses. The latter are believed to be responsible for the majority of cases of severe TTs. In this study, the coagulation performance, and the immediate and delayed tissue effects of laser coagulation were evaluated in an in vivo ovine model. Eight pregnant ewes of about 100 days' gestational age (term= 145 days) were studied. In utero coagulation was done through a 1.2 mm fetoscope loaded with a 600 microm laser fibre, connected to an Nd:YAG laser in continuous mode. Superficial cotyledonary vessels were coagulated under visual control at a distance of 1 cm with a mean power of 60 watts. 31 lasered cotyledons were harvested, either immediately (n= 15), 14 days (n = 8) or 42 days (n = 8) after the surgery and evaluated by inspection and histology. Control cotyledons were either neighbouring cotyledons from the same amniotic sac (internal control) or cotyledons from another gestational-age-matched sac (external control). Immediate effects consisted of localized coagulation necrosis at the zone of laser impact with no significant histological effect at more than 2 mm distance, except tissue congestion. Long-term effects consisted of fibrosis without any vascular recanalization or tissue regeneration extending from the impact site over the whole cotyledon. All treated cotyledons underwent complete infarction over time. This study provides experimental evidence supporting that laser coagulation of superficial chorionic vessels entering a cotyledon achieves complete functional elimination of the involved cotyledon.

Single-port tracheoscopic surgery in the fetal lamb.

BACKGROUND/PURPOSE: Endoscopic fetal surgery could help avoid many of the problems associated with open fetal surgery, but the use of multiple ports may be too traumatic to the membranes. The authors describe a single-port technique of tracheoscopic surgery in the fetus. METHODS: Time-dated pregnant ewes (95 to 105 days; term, 145 days) underwent midline laparotomy under general halothane anesthesia. A 5-mm-diameter balloon-tipped cannula was introduced in the uterus by Seldinger technique. A 1.2-mm semirigid mini-endoscope, fitted inside a 9F, 20 degrees curved sheath, was introduced under continuous, low-pressure irrigation, inside the fetus' mouth, and advanced into the trachea. RESULTS: Endotracheal procedures, including temporary (n = 11) and permanent balloon tracheal occlusion (n = 30) and placement of a barbed guide wire for endotracheal occlusion device insertion (n = 12), were performed by introducing a 1-mm diameter instrument alongside the telescope. These were successfully performed in 52 of the 53 fetuses. The rigidity of the telescope allowed controlled access to the pharynx; its curve allowed full tracheobronchial endoscopy with the fetus in utero. CONCLUSIONS: The present technique marries the control and optical quality of a rigid endoscope with the physiological curve only a flexible instrument could offer until now. The types of procedures performed with this technique illustrate its potential as a research tool; the size (1.2-mm diameter), shape, and optical qualities of the telescope should make clinical applications possible.

The plug-unplug sequence: an important step to achieve type II pneumocyte maturation in the fetal lamb model.

PURPOSE: The purpose of this study was to test the hypothesis that tracheal obstruction (plugging) in the fetal lamb model leads to a decrease in the absolute number of type II pneumocytes and that reversing the obstruction before birth (unplugging), allows the type II cells to recover while maintaining the beneficial effect on lung growth. METHODS: Nine time-dated pregnant ewes (term, 145 days), carrying 17 fetuses, were used in this surgical trial. The fetuses were divided into three experimental groups: group A underwent plugging at 93 days gestation, followed by unplugging at 110 days; group B animals had tracheal ligation at 93 days and group C consisted of unoperated controls. All fetuses were delivered by cesarean section at 136 days' gestation. The fetal trachea was obstructed with the tracheoscopically placed detachable balloon described by our group. Unplugging was performed by needle puncture of the balloon under tracheoscopic vision. Outcome measurements consisted of lung-to-body-weight ratio (LWBR), lung morphometry (mean terminal bronchial density [MTBD] and linear intercept [Lm]), and assessment of the number of type II pneumocytes. The latter was determined by in situ hybridization to the mRNA of surfactant protein-C, which is exclusively produced by type II cells. Statistics were calculated using a two-tailed unpaired t test and P less than .05 is considered significant. RESULTS: Seventeen animals are included in the results. All of them had lung samples analyzed for lung morphometry, whereas for type II cells analysis, three animals were studied in each group. Morphometric analyses were consistent with pulmonary hyperplasia for group B, whereas group A lungs showed more histological maturity than group C albeit not as marked as group B. In group A, there was a similar number of type II cells to that observed in group C (53.2 +/- 3.9 v 55.9 +/- 4.0, P = .66). However, for group B animals, the number of type II pneumocytes was markedly decreased compared with controls (4.7 +/- 0.1 v 55.9 +/- 4, P = .0003). CONCLUSIONS: The authors conclude that tracheal ligation until birth, although inducing pulmonary hyperplasia, significantly decreases the number of type II pneumocytes in the alveoli. After a temporary 15-day occlusion initiated at 95 days' gestation, there is complete normalization of the density of type II cells. These results bear importance on the duration of PLUG to treat the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Temporary tracheal obstruction now needs to be tested in a hypoplastic lung model.

Experience with fetoscopic cord ligation.

OBJECTIVE: In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data. STUDY DESIGN: Descriptive case series of four cases and review of the cases published up to 1996. RESULTS: We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks. CONCLUSION: Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model.

OBJECTIVE: Intra-uterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. We aimed to evaluate the feasibility and pulmonary effects of tracheoscopic tracheal obstruction with a detachable balloon. STUDY DESIGN: Fourteen mid-trimester fetuses out of 24 in 13 ewes underwent tracheoscopic balloon obstruction. Ten non-operated fetuses served as controls. Plugging was performed under fiber-tracheoscopy using a detachable balloon. Outcome measures consisted of: total operating time, tracheoscopy time, fetal survival, efficiency of plugging, and pulmonary effects. The Mann-Whitney test and linear regression were used for statistical analysis. RESULTS: Mean operating time and tracheoscopy time were 65+/-12 and 6.6+/-3.9 min, respectively. One intra-operative death occurred in each group. The post-operative mortality was 2/13 for cases and 2/9 for controls. In all 14 fetuses, the trachea was successfully obstructed. In the 11 treated animals born alive, the lung-to-body-weight ratio was 0.060+/-0.01, while in controls it was 0.031+/-0.01 (P = 0.0001). In a subset of six fetuses obstructed for 14-18 days, mean-terminal-bronchial density was 0.95+/-0.59, compared to 2.06+/-0.80 for controls (P = 0.046). CONCLUSIONS: Using fetal tracheoscopy, the trachea can successfully be obstructed with an inflatable balloon. Pulmonary hyperplasia is achieved when the obstruction lasts 2 weeks.

Intrauterine tracheal obstruction, a new treatment for congenital diaphragmatic hernia, decreases amniotic fluid sodium and chloride concentrations in the fetal lamb.

OBJECTIVE: To evaluate the effect of fetal tracheal occlusion on sodium and chloride concentrations in amniotic and tracheal fluid. SUMMARY BACKGROUND DATA: Intrauterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. In early human trials, technical failure of the obstructive device has been reported. METHODS: Eight fetal lambs (gestational age = 95 days) were subjected to fetal tracheoscopy, and amniotic and tracheal fluid samples were taken. In multiple pregnancies (n = 6), amniotic fluid was also sampled from the contralateral amniotic sac and used as a control. Subsequently, endotracheal obstruction, using a detachable balloon, was performed. After 14 days, all fetuses were delivered, and sodium and chloride concentrations in amniotic and tracheal fluid were measured again. Statistical analysis was done using a two-tailed Student's t test, paired or unpaired as appropriate. RESULTS: In controls, between 95 and 109 days gestational age, no significant changes occurred in sodium or chloride concentrations in amniotic or tracheal fluid. After 2 weeks of tracheal obstruction, however, chloride and sodium concentrations in amniotic fluid decreased (chloride = 76.7 mEq/L vs. 107.6 mEq/L, p = 0.0003; sodium = 109.6 mEq/L vs. 125.9 +/- 5.2 mEq/L, p = 0.019). A concomitant increase in chloride and sodium concentration was observed in tracheal fluid (chloride = 145.4 mEq/L vs. 130.0 mEq/L, p = 0.047; sodium = 153.1 mEq/L vs. 142.9 mEq/L, p = 0.051). When comparing groups at 109 days, chloride and sodium concentrations in amniotic fluid were markedly lower in the treated group versus controls (p = 0.0004 and p = 0.05 for chloride and sodium, respectively). CONCLUSION: Complete tracheal occlusion in ovine fetuses results in a significant decrease of amniotic fluid sodium and chloride concentrations.

Tracheoscopic endotracheal occlusion in the ovine model: technique and pulmonary effects.

BACKGROUND/PURPOSE: The purpose of this study was to assess the tracheoscopic placement of a detachable balloon to obstruct the trachea in the fetal lamb model and to study the pulmonary effects 2 weeks later. METHODS: Thirteen pregnant ewes carrying 27 fetuses were used in this trial. Thirteen fetuses underwent endotracheal plugging at a mean gestational age of 95 (90 to 100) days (term, 145). Fourteen nonoperated fetuses served as controls. The intended duration of obstruction was 15 days. Study parameters consisted of operating time, fetal survival, performance of the balloon, and pulmonary changes. RESULTS: Hysterotomy time was 41 +/- 25 minutes and tracheoscopy time was 7.2 +/- 3.4 minutes. There were no intraoperative deaths in this series. Postoperative fatalities occurred in 2 of 13 plugged fetuses and 1 of 14 controls. At completion of the experiment, the balloon was recovered intact in the trachea of 12 of 13 (92.3%) fetuses. The lung weight/body weight ratio was 76 +/- 16 mg/kg for plugged animals, while in controls it was 34 +/- 8 mg/kg (P = .0001). The lung volume/body weight ratio was 101 +/- 17 mL/kg in plugged fetuses, compared with 47 +/- 4 mL/kg for controls (P = .0002). Mean-terminal-bronchial-density was 0.937 +/- 0.303 for plugged animals, compared with 1.911 +/- 0.441 for controls (P = .0002). Mean linear intercept was 60.9 +/- 5.2 microm in treated fetuses, and 46.3 +/- 5.8 microm for controls (P = .0004). CONCLUSIONS: Fetal endotracheal occlusion, using a tracheoscopically placed detachable balloon, is reliable, and results in pulmonary hyperplasia after 2 weeks of obstruction. This technique may be beneficial in treating the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Further studies using this balloon device are now required to corroborate these findings.

Amnioinfusion with Hartmann's solution: a safe distention medium for endoscopic fetal surgery in the ovine model.

In this study, we have investigated the maternal effects of distending the uterine cavity with Hartmann's solution in 2nd trimester equivalent pregnant sheep. In 7 pregnant ewes, double endoscopic cannulation of the amniotic cavity was performed under general anesthesia, and 1 liter of Hartmann's solution at 38 degrees C, radiolabeled with 99mTc-red blood cells, was infused. Maternal central venous pressure, hematocrit, serum and amniotic fluid osmolarity, and amniotic fluid volume were measured at nine time points within a 2-hour period. Over this time interval, no significant fluid shift to the maternal compartment was observed. We detected no adsorption of radioactivity to the fetus or membranes, and no diffusion of radioactivity to maternal or fetal tissues was noticed. We conclude from these experiments that following double cannulation and intra-amniotic infusion of Hartmann's solution into the 2nd-trimester pregnant ovine uterus, no significant shift of fluid to the maternal compartment was observed over a 2-hour time period.

The effect of training and duration of surgery on adhesion formation in the rabbit model.

In order to evaluate the effect of training upon postoperative adhesions, standard bipolar and mechanical, nonopposing injuries were performed in the uterine horns and side walls of 52 mature female rabbits using a conventional three-puncture laparoscopy, by an endoscopic surgeon with limited experience. An additional injury, either bipolar or mechanical or both, was performed in the retro-uterine space. With experience, the duration of surgery decreased progressively from 12 +/- 2 to 8 +/- 1 min in the first and last 10 animals respectively. The amount of perioperative bleeding was not affected by experience. With experience the postoperative adhesions decreased in extent (P = 0.0001), tenacity (P = 0.004), type (P = 0.002) and inflammation (P = 0.003) and for total score (P = 0.0002). These changes were correlated with the briefer duration of surgery but not with the amount of perioperative bleeding. The strong correlations of adhesion scores in the pouch of Douglas, and around both uterine horns confirmed the importance of the inter-animal variability in making adhesions. By logistic regression, the adhesions in the pouch of Douglas were explained simultaneously by the adhesions on the uterine horns (P = 0.0004, thus correcting for inter-animal variability) by the amount of bleeding (P = 0.01) and the duration of surgery (P = 0.05). No major differences were found in adhesions following a mechanical or a bipolar injury or following such a lesion in the pouch of Douglas or at the uterine horns. In conclusion, experience, expressed by the duration of surgery and to a lesser extent perioperative bleeding, is a major co-factor in postoperative adhesions, suggesting that duration of surgery should be strictly standardized in endoscopic adhesion studies. The important inter-animal variability can be circumvented by using a standard control lesion, making each animal its own control.

Underwater Nd:YAG laser coagulation of blood vessels in a rat model.

Endoscopic coagulation of placental and umbilical cord vessels has been suggested as a treatment for selected cases of twin-twin transfusion syndrome and of acardiac twin. The feasibility, safety and hemostatic effect of neodymium:yttrium-aluminium-garnet (Nd:YAG) laser in an underwater environment were experimentally studied in an in vivo model, mimicking the in utero situation and fetoplacental vessels. In 10 male Wistar rats, immersed in normal saline at 38 degrees C, femoral vessels, carotid artery, abdominal aorta and vena cava were coagulated under endoscopic control. A 100-Watt Nd:YAG laser was used in continuous mode with a 600-micron fiber. Outcome measurements were vascular diameter, total energy (joules) used to obtain visual coagulation and subsequent vascular obliteration. Overall failure rate was 32% and perforation of the vessel occurred in 7.7% of cases.

Herniation through the foramen of Winslow. Report of two cases.

PURPOSE: Two clinical cases of internal herniation through the foramen of Winslow are presented. The first case concerns herniation of the cecum and ascending colon. In the second patient, the ileum was herniated through the foramen epiploicum. METHODS: Preoperative assessment of clinical and radiologic findings suggested diagnosis. RESULTS: Final diagnosis was only made at laparotomy. Reduction of hernia could be performed by pulse traction, and no signs of intestinal necrosis were seen. CONCLUSION: Herniation through the foramen of Winslow should be taken into account when making a differential diagnosis for upper gastrointestinal tract obstruction.