Management of anterior mediastinal masses in children.

BACKGROUND: Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons. METHODS: We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications. RESULTS: There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26). CONCLUSION: Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.

Outcome of congenital diaphragmatic hernia repair depending on patch type.

INTRODUCTION: Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials. METHODS: A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009. RESULTS: Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate. DISCUSSION: As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.

Use of a noncontact radiant heat bandage for the treatment of chronic venous stasis ulcers.

A noncontact radiant heat bandage was used for the treatment of chronic venous stasis ulcers (mean duration 4.44 years) in inpatients who had failed aggressive inpatient and outpatient conventional therapy. The noncontact radiant heat bandage was placed over the ulcer for 5 hours daily: three 1-hour heating periods separated by two 1-hour nonheating periods during this 2-week trial. Wound size, status, and pain severity were recorded for each patient. A total of 17 patients with 31 total wounds were enrolled. No adverse effects were noted in any patient. There was improvement in 14/17 total patients during the 2-week inpatient trial and 8/17 patients healed completely after discharge. There was 1 recurrence during an 18-month follow-up. Pain scores were improved in most patients after the bandage was applied. The use of a noncontact radiant heat bandage is a safe and efficacious inpatient therapy for the management of chronic venous stasis ulcers in patients who have failed conventional therapy.