Pushing the boundaries of ECLS: Outcomes in <34 week EGA neonates.

PURPOSE: Extracorporeal life support (ECLS) is usually reserved for infants ≥34weeks estimated gestational age (EGA) owing to concerns about increased mortality and incidence of intracranial hemorrhage (ICH). We sought to characterize survival, rates of ICH, and complications in <34week EGA neonates placed on ECLS. METHODS: 752 neonates of EGA 29-34weeks were identified in the Extracorporeal Life Support Organization (ELSO) Registry (1976-2008). Data analyzed included birthweight, survival, pre-ECLS conditions, ventilatory parameters and complications (including ICH and other neurological outcomes). Data were compared using t-test, Chi-square and logistic regression analyses. RESULTS: When compared to survival rates of 34week EGA neonates (58%), survival was statistically different for 29-33week EGA (48%, p=0.05). No significant difference in ICH incidence was seen between the 29-33week and 34week groups (21% vs. 17%, respectively), but a significant difference was seen in the incidence of cerebral infarct between groups (22% for 29-33weeks vs. 16% for 34weeks; p=0.03). ICH and survival did not correlate with EGA during logistic regression analysis. CONCLUSIONS: Though rates of survival and cerebral infarction were worse at 29-33weeks EGA compared with 34weeks, these differences were modest and may be clinically acceptable. This suggests that EGA<34weeks may not be an absolute contraindication to use of ECLS. LEVEL OF EVIDENCE: III.

Appendicostomy for intraluminal antibiotic administration and extracorporeal membrane oxygenation support in severe Hirschsprung's enterocolitis.

A term male infant with Hirschsprung's disease underwent an uncomplicated laparoscopic-assisted endorectal pull-through procedure. Four weeks after discharge, the patient developed severe Clostridium difficile enterocolitis with hemodynamic instability and peritonitis. Bedside laparotomy confirmed intestinal viability and accommodated an appendicostomy for antegrade vancomycin colonic irrigations. The patient required venoarterial extracorporeal membrane oxygenation for physiological support for more than six days. Transition to conventional support was successful with survival and discharge from the hospital free from hemorrhagic complications. The patient is now developmentally appropriate for his age.

Premenarchal ovarian torsion and elevated CA-125.

BACKGROUND: Ovarian tumors are the most common gynecologic malignancy occurring in childhood, with germ cell tumors being most frequent. This contrasts with adults where epithelial tumors account for most ovarian neoplasms. Tumor markers are an integral part of the work-up and may guide management. CASE: A 6-year-old girl with a persistent adnexal mass was found to have a highly elevated CA-125. Other tumor markers were normal. Laparoscopy revealed an enlarged, adherent ovary. A minilaparotomy revealed an ovary filled with necrotic material. This necrotic material was excised and the ovary was spared. The pathology was consistent with necrosis. Follow-up ultrasonography and CA-125 were normal. SUMMARY AND CONCLUSIONS: This case demonstrates for the first time the association of an elevated CA-125 and ovarian torsion in a pediatric patient. This benign finding allowed attempting a conservative ovary-sparing approach during the surgery even in the presence of a highly elevated CA-125. However, in general, for children CA-125 is of limited utility, as it will not affect the indication for surgical exploration of persistent masses and elevations in CA-125 may discourage ovarian conservation.