The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease.

OBJECTIVE: A variety of stents are available to aid in the management of complex tracheal, carinal and bronchial stenoses. We reviewed our multi-institutional experience with airway stents in children. METHODS: Thirty-three children (age, 13 days-18 years) from four institutions have had a total of 40 stents placed to aid in the management of complex airway stenoses. Three stent types were utilized: 29 silastic stents, five expandable metal stents and six customized carinal stents (four patients had two stents and one patient had four stents). Thirty children had tracheal stents, six children had bronchial stents, and two infants had carinal stents (three children had stenting of more than one area and two had stenting of all three locations). Twenty-eight patients (age, 5 months-18 years; mean, 8.06 years; SEM, 1.13 years) had stents placed after a variety of airway reconstructive procedures. Four underwent stenting in a non-operative setting and one as preoperative stabilization. RESULTS: Twenty-seven patients survived. One patient died early due to bleeding. Five patients died late: two due to bleeding, one from mediastinitis, and two patients with functional airways died late from unrelated problems. Complications are related to stent type and location. Carinal stents can migrate; several techniques are available to help manage this problem. Wire stents are essentially non-removable requiring periodic dilation. Silastic stents stimulate granulation tissue formation requiring periodic bronchoscopic removal. CONCLUSION: Tracheal stenting can aid in the management of pediatric airway problems. Complications are common, but can be managed with appropriate intervention.

Identifying Blalock-Taussig shunts using a Silastic band.

Placement of an encircling Silastic band around Blalock-Taussig shunts facilitates identification and ligation of the shunt at the time of corrective operation. This technique of "shunt banding" is particularly useful for left-sided shunts, both native and modified. We have noted no complications, specifically shunt constriction. Placement of the band adds minimal operative time during shunt placement and substantially lessens the time and amount of dissection required during subsequent procedures.

Familial cardiac myxoma.

The majority of cardiac myxomas occur sporadically as isolated lesions in the left atrium of middle-aged women. However, a "familial" form and a "syndrome" form of this lesion have been identified. The syndrome myxoma can present with pigmented skin lesions and peripheral or endocrine neoplasms. The familial and syndrome forms of cardiac myxomas can usually be distinguished from the sporadic form by the presentation at a younger age, the unusual location and multicentricity of the lesions, and the presence of rare pathological conditions. In addition, a higher rate of recurrent lesions is usually associated with the familial and syndrome forms of this disease. To date, 15 families with cardiac myxomas have been reported in the world's literature. Here we present 2 additional case reports.

Spontaneous pneumoperitoneum. A surgical dilemma.

Pneumoperitoneum is usually the result of hollow viscus perforation with associated peritonitis. Nonsurgical spontaneous pneumoperitoneum incidental to intrathoracic, intra-abdominal, gynecologic, iatrogenic, and other miscellaneous causes not associated with perforated viscus have been documented in the literature. Seven cases of spontaneous pneumoperitoneum admitted over 3-year period to Grady Memorial Hospital, Atlanta, Georgia are reported. Six patients with pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in any of these patients. A seventh patient, on ventilatory support, was managed conservatively after performing a diagnostic peritoneal lavage that was negative. There were no cases of radiographically misdiagnosed pneumoperitoneum. Pneumoperitoneum, preceded by a reasonable incidental cause in a patient with a adequate abdominal examination, may warrant continued observation thus avoiding an unnecessary laparotomy.

Continued propranolol administration following coronary bypass surgery. Antiarrhythmic effects.

One hundred consecutive patients requiring propranolol hydrochloride before undergoing isolated aortocoronary bypass procedures were examined. In half the patients, propranolol therapy was discontinued, whereas the other half continued to receive intraoperative and postoperative propranolol regardless of clinical events. Although there were no preoperative differences in the apparent degree of coronary arterial disease or left ventricular function in the two groups, postoperative supraventricular arrhythmias were less frequent in the propranolol-treated group, most noticeably in those receiving less than 320 mg preoperatively. In patients who had received large preoperative doses (greater than or equal to 320 mg/day), there were no significant differences in postoperative supraventricular tachycardias. Continued propranolol therapy following isolated coronary bypass surgery appears to be a safe and efficacious method of decreasing the incidence of postoperative supraventricular tachycardias.

Should nutritional status be assessed routinely prior to cardiac operation?

One hundred consecutive adult patients undergoing cardiac operations at a single institution were evaluated preoperatively with regard to their nutritional status. Anthropometric, biochemical, and immunologic characteristics were evaluated in addition to cardiac biopsy specimens to determine right atrial glycogen concentration. Although some positive anthropometric, biochemical, and cell-mediated immunity characteristics were observed to have "statistically significant" correlations with morbidity and mortality for the group as a whole, nearly all of the values remained near or at normal limits. Lighter weight men with a smaller arm muscle circumference and lower concentration of total body fat had more complications than their heavier counterparts. Serum transferrin and cell-mediated immunity also formed weakly positive statistical correlations. Anthropometric correlations in women were of no value. Myocardial glycogen concentrations did not correlate with postoperative morbidity and mortality. Because nearly all of the patients had arteriosclerotic heart disease, the series as a whole may have been skewed toward a group with values too close to normal to differentiate them adequately. It is concluded that routine nutritional assessment is of no value in guiding nutritional management for individual patients, although when patients are analyzed as a group, interesting epidemiologic observations can be made.