Cystic neuroblastoma of infancy.

Cystic neuroblastoma is exceedingly rare; only 29 cases have been reported in the medical literature. The authors treated two children with cystic neuroblastoma. The first was a 2-week-old boy with an adrenal lesion; the second was a 15-month-old girl with solitary thoracic cystic neuroblastoma. Cystic neuroblastoma is located, almost exclusively, in the adrenal gland. In contrast to solid neuroblastoma, cystic neuroblastoma has a benign course. Cystic neuroblastoma is diagnosed earlier than solid neuroblastoma, and the former rarely presents with metastatic lesions. All previous reported cases of cystic neuroblastoma were diagnosed before 21 months of age. The presence of calcification was rare, and only 9.5% had documented elevation of the vanillylmandelic acid or homovanillic acid level. Surgical resection of all gross tumor was accomplished in 86% of children with cystic neuroblastoma, and in this group none of the patients had reported recurrent disease. Both present cases also had surgical resection of the entire gross tumor, and likewise have had no evidence of recurrent disease. This report brings the total number of reported pediatric cases of cystic neuroblastoma to 31; to the authors' knowledge, this is the first report of a child with solitary cystic neuroblastoma in an intrathoracic location.

Selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass.

Thirty-six (4.6%) patients required exploration for hemorrhage after 788 coronary artery bypass grafting procedures. Twenty-three (64%) patients with a specific site of bleeding that was surgically controlled or with improving coagulopathy were managed by immediate sternal closure. Continued hemorrhage or tamponade necessitated reexploration in 5 of these patients. All 5 patients were then treated by open sternotomy and delayed sternal closure. There were no deaths or sternal wound infections in this subgroup. Thirteen (36%) patients explored for hemorrhage were initially treated by open sternotomy and delayed sternal closure because of ongoing coagulopathy with refractory bleeding. Twelve patients recovered without further complication. One patient died 30 days after delayed sternal closure. There were no sternal wound infections. This experience supports a selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass grafting. Immediate closure is recommended if a specific site of bleeding can be located and corrected. However, in the presence of refractory hemorrhage due to coagulopathy, delayed sternal closure should be considered to avoid the subsequent morbidity of continued bleeding, including cardiac tamponade, multiple reexplorations with sternal trauma, and retained mediastinal hematoma.

Delayed primary closure after sternal wound infection.

Infected median sternotomy is a major complication of cardiac operations. Over a 30-month period, 25 sternal wound infections were treated at a single institution. Twenty-four (2.7%) followed 883 operations with cardiopulmonary bypass, and 1 followed median sternotomy for a noncardiac procedure. Twenty-one of the 25 patients survived to sternal closure. Eighteen patients were treated with delayed primary closure and 3 with pectoralis muscle flaps. Fifteen patients (83%) had an uneventful postoperative course after delayed primary closure. In 2 patients reoperation was required for sternal dehiscence, and in 1 patient a superficial wound infection developed, which was treated with local wound care. In all 18 patients the sternum eventually healed. Criteria for delayed primary closure included clean tissue surfaces without purulent debris, the absence of pockets of purulent drainage, and negative wound cultures obtained 24 hours before closure. The average time from operation to sternal incision and drainage was 11 days (range, five to 59 days). Delayed primary closure was performed nine days after incision and drainage (range, five to 27 days). The average hospital stay was 24 days after sternal incision and drainage (range, nine to 85 days). Cultures from specimens taken at the time of sternal incision and drainage were positive in all patients. Wound cultures were positive at the time of sternal closure in 5 patients. Wound complications developed in 2 of these 5 patients. Delayed primary closure has many of the advantages of classic methods, but fewer complications. Results are comparable, while allowing simpler wound care and less cosmetic deformity. Delayed primary closure is an acceptable alternative in the treatment of sternal wound infections.

Mesenteric vascular insufficiency and claudication following acute dissecting thoracic aortic aneurysm.

Mesenteric vascular insufficiency and claudication of the left leg were observed in a patient 6 weeks after intraluminal aortic prosthesis placement for acute type III thoracic aortic dissection. Aortography revealed double-channel deformity of the thoracoabdominal aorta and complete occlusion of the celiac axis, inferior mesenteric artery, and left common iliac artery. An aortobi-iliac interposition graft placed end to end with an additional limb to the common hepatic artery was curative.

Fracture and embolization of a Björk-Shiley disc. Fatal failure of a prosthetic mitral valve.

A case of fracture of the disc occluder of a Bjork-Shiley mitral prosthesis with embolization of the disc fragments to distal aorta is presented. The possibility of valve dysfunction and the diagnostic value of echocardiography should be considered whenever acute heart failure occurs in a patient with an artificial valve.

Functional capabilities following coronary bypass surgery.

Changes in myocardial oxygen supply were evaluated in 19 patients following coronary by-pass surgery (CBS) for angina pectoris (AP). A symptom limited maximal functional graded exercise test (GXT) was performed before and 2-19 (X 7.5) months following CBS. After surgery the patients were urged to resume full activity and were individually managed in a 10-week "at home" exercise program. Increases were demonstrated for predicted oxygen uptake and work load (p less than .002), and rate pressure product (p less than .02) following CBS, suggesting increased myocardial blood flow. Terminal heart rate showed no significant increase. Of 16 patients exhibiting ST segment depression ( greater than or equal to .1 mV) with AP during GXT before surgery, 10 cases experienced total relief of both of these signs after surgery. A correlation between the pre-operative number of occluded coronary arteries (greater than 50%) and the degree of exercise induced ST segment depression revealed no significant trend. Additionally, no significant relationship was found between post-operative GXT results and the number of by-pass grafts performed on each patient. This study supports the premise that the effectiveness of CBS, in improving functional capacity, can be objectively evaluated by a non-invasive functional GXT.