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Biomedical subjects

J C Langer

Publications and source records attributed to J C Langer.

At least 127 records · Page 7Linked to original sources
PubMed1989

Survival after emergency department thoracotomy in a child with blunt multisystem trauma.

A 14-year-old boy sustained severe blunt, multisystem trauma. On presentation, vital signs were present but disappeared despite maximal resuscitation. Emergency department thoracotomy (EDT) resulted in return of vital signs and transfer to the operating room for a definitive procedure. Ultimately, the child survived with normal neurologic function and quality of life. This case illustrates the potential value of EDT in selected patients who present with detectable vital signs and deteriorate in the face of maximal conventional therapy.

Adolescent↗
PubMed1989

Ontogeny of the smooth muscle response to histamine in rabbit and human small bowel.

Histamine is known to stimulate small bowel smooth muscle contraction in adults. We studied the response to histamine of small bowel from 27 day gestation fetal (term = 31 days), 4 days-old neonatal, and weanling rabbits using an isolated muscle strip technique in vitro. Sensitivity to histamine stimulation decreased with increasing age, with a six-fold difference in mean D50 between fetal and weanling bowel. A strong contractile response was also obtained in human fetal bowel between 16 and 24 weeks gestation. The response to histamine was inhibited at all ages in both rabbit and human bowel by specific histamine H1 receptor blockade with diphenhydramine, and not by H2 or cholinergic receptor blockers. We conclude that histamine stimulates rabbit and human fetal small bowel contraction; stimulation specifically occurs via the histamine H1 receptor, and is unrelated to release of acetylcholine; sensitivity to histamine decreases significantly with maturity in the rabbit.

Animals↗
PubMed1989

Neonatal model of heterotopic heart transplantation in pigs.

To investigate the long-term success of heart transplantation in newborn infants who have complex congenital heart disease, we have developed a model of heterotopic heart transplantation in immature pigs. We chose the heterotopic technique because it is simple, does not require cardiopulmonary bypass or heparin, allows for significant size disparity between the recipient and donor hearts, and allows for experimental comparisons between the two hearts. Small newborn piglet hearts are harvested, prepared, and then transplanted into the left chest of larger weanling pigs to augment or substitute for the native left ventricle. Preliminary data from transplants into 49 pigs suggest that the technique is technically possible, the pigs can be immunosuppressed over the long term, and the donor heart can contribute hemodynamically. Experimentally, the model is well designed for the investigation of issues critical for the long-term success of heart transplantation in infants and children, including growth and development, optimal long-term immunosuppression, differences in immunotolerance, and the study of coronary obliterative disease. Clinically, the model has potential applicability in congenital heart anomalies if one native functioning atrium and ventricle are present.

Animals↗
PubMed1988

Prenatal diagnosis and management of bilateral hydronephrosis.

This report reviews the management of the fetus with congenital hydronephrosis (CH), a challenging diagnostic and therapeutic problem. Experimental models of obstructive uropathy have produced histologic changes similar to those seen in kidneys of human neonates with congenital hydronephrosis. Relief of obstruction in utero in these models has been shown to prevent some of the dysplastic changes caused by obstruction. These studies have formed the theoretical basis for in utero decompression to restore amniotic fluid dynamics to prevent death from pulmonary hypoplasia, and reverse or arrest dysplastic morphogenesis. The development of prognostic criteria has greatly aided in selection of appropriate fetuses for intervention. These criteria include: (1) Na less than 100 mEq/l; (2) Cl less than 90 mEq/l; (3) osmolarity less than 210 mosmol; (4) sonographic appearance of the fetal kidneys; (5) amniotic fluid status; (6) urine output at fetal bladder catheterization. All fetuses should have ultrasonography to exclude other anomalies, and karyotype analysis to exclude chromosomal abnormality. If amniotic fluid volume is normal, the pregnancy is followed with serial ultrasound examinations. If oligohydramnios develops, a prognostic evaluation is performed, including fetal bladder catheterization. If the fetus has poor residual renal function, on the basis of prognostic criteria, appropriate counseling may be given. If the fetus has good residual renal function, depending on lung maturity, it can be delivered early for corrective surgery. If diagnosed prior to lung maturity in utero, decompression by either vesicoamniotic shunting or open fetal surgery may be attempted in the highly selected case.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

Early experience with open fetal surgery for congenital hydronephrosis.

The fetus with severe bilateral hydronephrosis and associated oligohydramnios in the second trimester is doomed at birth by ongoing pulmonary and renal damage. Since decompression with percutaneously placed catheters anesthetic, surgical, and tocolytic techniques for open fetal anesthetic, surgical, and tocolytic techniques for open fetal urinary tract decompression in animals, and have now applied those techniques to a small group of five patients. One had bilateral ureterostomies and the subsequent four had marsupialization of the bladder. All pregnancies proceeded to cesarean delivery at 32 to 35 weeks' gestation. There was no long-term maternal morbidity, and two mothers have since experienced normal pregnancies. Three fetuses had return of normal amniotic fluid dynamics, and all three had adequate pulmonary function at birth, suggesting that fatal pulmonary hypoplasia associated with early severe oligohydramnios had been reversed. Two neonates died at birth with pulmonary hypoplasia. One had no amniotic fluid even after decompression, and the other had some amniotic fluid after decompression but a tiny chest cavity due to the long period of severe oligohydramnios before decompression. Of the three surviving infants, one had normal renal function when she died of unrelated causes at 9 months of age. One has normal renal function at 23 months and the third had failing renal function at 2 1/2 years and has grown and developed normally, but will require renal transplantation. We have now developed selection criteria that would exclude from treatment the two fetuses who died of pulmonary hypoplasia and the one who developed renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Central venous catheters--no X-rays needed: a prospective study in 50 consecutive infants and children.

A technique of central venous line (CVL) placement using ECG guidance is described. The method utilizes equipment found in most operating room departments, is easily learned and taught, and obviates the need for x-rays. CVL placement in 50 consecutive infants and children was performed over a 4-month period by the ECG-guided method, with catheter tip position subsequently determined by x-ray study. The technique demonstrated a 96% success and 100% accuracy rate. The two technical failures were both preventable. Equipment malfunction was responsible for one failure. The second failure was secondary to a preexisting supraventricular arrhythmia, and patients with arrhythmias or pacemakers are not suitable candidates for this technique of central venous catheterization. Radiologic methods of CVL placement were necessary in these two patients.

Adolescent↗
PubMed1988

Timing of surgery for congenital diaphragmatic hernia: is emergency operation necessary?

Congenital diaphragmatic hernia (CDH) is considered by most researchers to be a surgical emergency. However, early repair does not necessarily improve respiratory function or reverse fetal circulation, and many patients deteriorate postoperatively. As a result, in 1985, we began to employ a protocol in which surgery was delayed until the PCO2 was maintained below 40 and the child was hemodynamically stable; children in whom these criteria could not be achieved died without surgical repair. Sixty-one consecutive infants with CDH were managed over 4 years; 31 from 1983 to 1984 (group 1) and 30 from 1985 to 1986 (group 2). The groups were similar with respect to sex, side of the defect, birth weight, gestational age, incidence of pneumothorax, and blood gases. High frequency oscillation was used with increasing frequency during the study period, for patients with refractory hypercarbia (13% in group 1, 30% in group 2). All patients were initially paralyzed and ventilated. Mean time from admission to surgery was 4.1 hours in group 1 and 24.4 hours in group 2 (P less than .05). In group 1, 87% of patients had surgical repair (77% within eight hours of admission, 10% after eight hours), and in group 2 only 70% of patients had surgery (10% within eight hours, 60% after eight hours). All patients who were not operated on died. Overall mortality was 58% in group 1 and 50% in group 2; this difference was not statistically significant. These data indicate that our current approach has not increased overall mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergencies↗
PubMed1988

Plication of the diaphragm for infants and young children with phrenic nerve palsy.

Phrenic nerve palsy (PNP) is seen in infants and young children usually resulting from operative trauma or birth injury. Spontaneous recovery usually occurs, but occasionally surgical plication is necessary. Twenty-three cases of PNP over a 10-year period were managed surgically. Patient ages ranged from 1 day to 30 months (median, 4 months), 18 were male and five female. Cause was operative trauma in 18 (17 cardiac surgery, one neuroblastoma), birth trauma in two, and idiopathic in three. The right side was involved in 14, the left in eight, and both in one. Indications for plication were inability to wean from the ventilator (group 1, 16 patients), recurrent pneumonia (group 2, four patients), and respiratory distress (group 3, three patients). The 16 patients in group 1 were intubated for a median of 18.5 days from onset of PNP to plication. Postoperatively, three had continuing congestive heart failure (one died at 16 days of age, one was still chronically ventilated at 22 months, one was extubated at nine days); the other 13 were extubated at a median of two days postoperatively. All the patients in groups 2 and 3 were extubated within two days of surgery. Twelve plications were transthoracic and 11 were transabdominal. Postoperative complications included pneumonia (2), wound infection (1), pneumothorax (2), and mucous plug with pulmonary collapse (1). One patient died of cardiac failure at 16 days. One patient in group 3 developed recurrent respiratory distress 4 months postoperatively; he had a recurrent elevated hemidiaphragm requiring a second plication.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗
PubMed1987

Intraoperative bupivacaine during outpatient hernia repair in children: a randomized double blind trial.

Postoperative pain is a major problem following surgery in the ambulatory child. A study was undertaken to test the effect of intraoperative bupivacaine on postoperative pain in children undergoing outpatient hernia repair. Ninety-nine children aged 1 to 7 years underwent outpatient inguinal herniorrhaphy under general anesthesia. Each was randomly assigned to receive bupivacaine (group 1) or saline (group 2), infiltrating the ilioinguinal and iliohypogastric nerves. Drug administration and patient evaluation were double-blinded. The groups were similar with respect to age, sex, side of procedure, and length of operation. In the immediate postoperative period, 17 group 1 patients required analgesics compared with 39 in group 2 (P less than .01); total codeine dosage was lower in group 1 (4.0 +/- 7.1 mg v 11.8 +/- 10.5 mg, P less than .05). Activity level 45 minutes after surgery (using a standardized scale) was greater in group 1 (P less than .05). Acetaminophen requirements at home were lower in group 1 on the day of surgery (3.1 +/- 4.3 mL v 5.7 +/- 7.4 mL, P less than .05) and over the following 48 hours (1.5 +/- 3.4 mL v 4.9 +/- 10.7 mL, P less than .05). Activity level at home on the day of surgery did not differ significantly between groups, but activity level over the following 48 hours was higher in group 1 (P less than .05). The two groups were similar with respect to all other parameters. We conclude that intraoperative bupivacaine decreases post-operative pain and analgesic use, and promotes early ambulation in children undergoing hernia repair.

Ambulatory Surgical Procedures↗
PubMed1987

Congenital diaphragmatic hernia: current controversies in prenatal and postnatal management.

A prenatal diagnosis of congenital diaphragmatic hernia (CDH) is associated with a poor prognosis, especially if diagnosed early in gestation and associated with polyhydramnios. Although uncommon, it is important to rule out associated anomalies, so that elective termination can be considered. If CDH is an isolated anomaly, the outcome is related to the degree of pulmonary hypoplasia caused by viscera displacing the lung in utero. Unfortunately, our ability to assess lung size, and thus prognosis, is limited. Most babies with CDH either die shortly after birth or survive to lead normal lives, so that continuation of the pregnancy is extremely unlikely to produce a chronically ill pulmonary cripple. The fetus should be followed with periodic ultrasounds and delivered at a perinatal center with appropriate neonatal and surgical expertise. There is no evidence that altering the timing or mode of delivery affects outcome. The only way to alter outcome and save the severely affected fetus is to remove the viscera from the chest and allow the fetal lung to develop before birth. Despite the fact that fetal repair of CDH makes sense physiologically, however, it remains a highly experimental technique. Postnatal management of CDH involves resuscitation, paralysis, and positive pressure ventilation. The practice of emergency repair is not supported by pathophysiology, and operation should be delayed until the patient has been stabilized. Mortality is often due to pulmonary hypoplasia, but in some cases, there is a period of deterioration due to pulmonary hypertension resulting in right-to-left shunting (persistent fetal circulation). Pharmacological agents are often used to decrease pulmonary vascular resistance and increase cardiac output.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed1987

Perinatal management of the fetus with an abdominal wall defect.

The antenatal diagnosis of abdominal wall defects has allowed improved perinatal management. For fetuses with associated anomalies, the options of elective termination or minimal intervention can be offered. Our ability to predict the extent of bowel damage in gastroschisis based on the ultrasound findings enables us to offer early delivery to those fetuses who are at high risk. The data are not clear at the present time whether cesarean section offers any advantage. These fetuses should, however, be delivered at a center which is capable of providing high level medical and surgical care to these potentially ill infants. Initial resuscitation of these neonates requires early insertion of an intravenous line and a nasogastric tube, the administration of antibiotics, sterile coverage of the eviscerated bowel, and careful attention to temperature instability. Neonates with gastroschisis should be operated on as soon as they are stable, whereas infants with omphalocele can be investigated for associated anomalies prior to surgery. Primary fascial closure is performed whenever possible. Where this is not possible, a staged repair using a silastic chimney achieves closure within 3-6 days. Skin coverage alone or nonoperative management is reserved for the few cases with giant omphalocele, associated anomalies, or poor operative risk. Decisions about primary versus delayed closure, while usually dictated by clinical judgement, can be aided by indirect measurement of intraabdominal pressure. Postoperative ventilation, and consideration of long-term nutritional needs, are also important parts of the perioperative management.

Abdominal Muscles↗
PubMed1985

Radiofrequency hyperthermia as adjuvant therapy following surgical resection of an experimental malignant neoplasm.

Local recurrence after radical surgery is a major problem with many primary solid cancers. The use of radiofrequency hyperthermia (RFHT) as adjuvant therapy to surgery was explored in the Fischer bladder carcinoma (FBCa)/F344 rat tumor system. After subcutaneous innoculation of 34 rats with 10(6) FBCa cells in suspension, RFHT was administered to 17 animals on days 1, 5, 8, and 12. The development of palpable tumors was delayed but not prevented, and tumor growth was retarded in RFHT-treated animals. In another experiment 40 rats were innoculated by subcutaneous trocar injection with a 1 mm3 piece of FBCa. After tumor excision on day 17, adjuvant therapy (untreated control, mitomycin C, RFHT, or RFHT plus mitomycin C) was started on day 20 (10 rats/treatment). The 20 RFHT-treated rats had only 1 incisional recurrence as compared to 9 recurrences in sham-heated rats (P less than 0.005). The authors conclude that RFHT has considerable value as adjuvant therapy to surgery in these tumors. Additional studies of RFHT as adjuvant treatment after surgical excision of tumors are planned.

Animals↗
PubMed1985

Carcinoma of the extrahepatic bile ducts: results of an aggressive surgical approach.

Ninety patients with adenocarcinoma of the extrahepatic bile ducts were treated between 1969 and 1984. Fifty-four tumors involved the upper third, 15 the middle third, and 21 the lower third of the common duct. Twenty-two patients had gallstones and five had inflammatory bowel disease. Forty-three patients had operations before definitive treatment; the diagnosis was made in only 18. Resection was accomplished in 30 patients (33%): 12 of 54 in the proximal third, six of 15 in the middle third, and 12 of 21 in the distal third. The mean survival in patients who underwent resection was 32 months (proximal third, 28 months; middle third, 32 months; lower third, 37 months). Surgical bypass was performed in 28 patients (mean survival 10 months) and intubation alone was performed in 24 patients (mean survival 8 months). Recurrent cholangitis occurred in 56% of intubated patients compared with 26% of patients treated without tubes. Radiation was used with resection and for palliation. Responses were observed, but the complication of radiation duodenitis has limited the dose. An aggressive approach to resection of bile duct tumors is possible with a low operative mortality rate and offers the best opportunity for cure as well as good palliation. Internal bypass is preferable to chronic intubation. The role of radiation therapy in this disease is still not clear.

Adenocarcinoma↗
PubMed1984

Management of patients with polyps containing malignancy removed by colonoscopic polypectomy.

The management of malignant colonic polyps removed colonoscopically has been a controversial subject. A continuing series is reported of 36 patients with 37 malignant polyps removed by colonoscopic polypectomy (CP) between 1976 and 1982. Fourteen polyps contained carcinoma in situ (CIS); 13 were treated by CP alone; one was treated by CP and colectomy. Nineteen polyps contained invasive carcinoma; 13 were treated by CP alone; six were treated by CP and colectomy. Four patients had sessile polyps resected piecemeal, in which accurate staging was impossible. Two were treated with CP alone, and two had CP plus colectomy. All patients were followed with yearly colonoscopy and/or barium enema. Follow-up has been six to 84 months (mean 36 months). Twenty-seven patients whose polyps were treated by CP alone have had no evidence of recurrent tumor at the polypectomy site. Of the nine patients undergoing colectomy, six had residual tumor at the polypectomy resection site. No patients had involved lymph nodes. Our current approach to this problem is based on the degree of invasion and the status of the resection margins. Polyps containing CIS can safely be treated with CP alone. Polyps with invasive carcinoma and clear resection margins should be treated with CP and either colectomy or frequent repeat colonoscopy. This decision is a clinical one and must involve input from both the clinician and the pathologist. Those polyps whose resection margins are involved or where piecemeal excision precludes accurate pathologic assessment should undergo colectomy.

Adenoma↗
PubMed1984

Surgical management of persistent neonatal hypoglycemia due to islet cell dysplasia.

We have reviewed ten children who underwent surgical therapy for persistent neonatal hypoglycemia over a 5-year period. All had inappropriately high insulin levels in the face of hypoglycemia, and all failed medical management with intravenous glucose, frequent feeds, diazoxide and glucagon. Two groups of five patients each were analysed retrospectively. Group 1 underwent 95% pancreatectomy, leaving a small amount of pancreatic tissue on the duodenum and common bile duct. The only major complication in this group was in one patient with common duct obstruction requiring choledochoduodenostomy. All these children are developing normally, without diabetes, steatorrhea, or recurrent hypoglycemia. Group 2 underwent 85% pancreatectomy, leaving the uncinate process in situ. Two of these children are well. Two required conversion to 95% resection because of recurrent hypoglycemia; one of these required a subsequent total pancreatectomy, at which time the pancreatic remnant had significantly regenerated. The other Group II patient was normoglycemic but died at age 3 from pneumonia. Pathology in nine cases showed islet cell dysplasia; 5 of these also had microadenomatosis. One case had a histologically normal pancreas. We conclude that 95% pancreatectomy is a safe operation with a lower failure rate than less radical resections, and should be used early in the management of this condition.

Female↗
PubMed1984

Diagnosis and management of hydatid disease of the liver. A 15-year North American experience.

Since 1967, 40 patients with hydatid disease of the liver have been treated at our hospital. Diagnosis was made using clinical criteria, serology, skin tests, and imaging techniques. Thirty-five patients were operated upon. In 18 patients the cyst was uncomplicated (Group I), and in 17 the cyst was infected or communicated with the biliary tract (Group II). Three forms of surgical treatment were used: A) cyst evacuation, scolicidal irrigation, and primary cyst closure, B) evacuation, irrigation, and external drainage, and C) complete or partial cyst resection. Mebendazole was used in six patients, four of whom were also treated surgically. In Group I, one of 11 patients (8%) treated by primary closure had complications, versus four of five patients (80%) treated with external drainage (p less than 0.001). Mean postoperative hospital stay for these two groups was 11.8 versus 20.8 days, respectively (p less than 0.001). Complication rates in Group II were higher, and were evenly distributed among treatments. Patients have been followed yearly, with a median follow-up of 5 years. Active hydatid disease has been found in three patients, who all had known residual disease at initial operation. The best treatment for an uncomplicated hydatid liver cyst is evacuation, scolicidal irrigation, and primary closure. External drainage is used for infected cysts or those communicating with the biliary tract, and excision for extrahepatic and peripheral, easily resectable cysts. Mebendazole is used for intraperitoneal spillage of cyst contents and in patients with inoperable disease.

Adult↗
PubMed1984

Palliation of advanced head and neck cancer with radiofrequency hyperthermia and cytotoxic chemotherapy.

Fourteen patients with recurrent malignant tumours of the head and neck were treated with radiofrequency hyperthermia and chemotherapy after conventional therapy had failed. After 2 to 11 treatment courses and a follow-up of 30 weeks, the neoplasms in three patients had completely regressed and one had a partial response. Of eight patients who died, two had partial responses initially; a third patient died of complications relating to surgical resection of the tumour after a partial response. Three of five patients whose tumours were unresponsive to methotrexate responded when this drug was given with radiofrequency hyperthermia. There were seven minor skin burns in six patients. Further studies of radiofrequency hyperthermia and chemotherapy for palliation of head and neck cancer are planned.

Adult↗