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R B Hirschl

Publications and source records attributed to R B Hirschl.

At least 37 records · Page 2Linked to original sources
PubMed1999

Predictors of malignancy in childhood peripheral lymphadenopathy.

PURPOSE: The aim of this study was to identify factors associated with malignant etiologies of childhood peripheral lymphadenopathy and to construct a model that may be used to assess the risk of malignancy. METHODS: The medical records of 60 consecutive patients 18 years old or less who underwent peripheral lymph node biopsies were reviewed. RESULTS: Increasing node size, number of sites of adenopathy, and age were associated with an increasing risk of malignancy (P < .05 for all variables). Graphs useful for risk determination were constructed based on these variables. Additional factors associated with malignancy included the presence of supraclavicular adenopathy (P < .01), an abnormal chest x-ray (P < .01), and fixed nodes (P < .01). Variables that were not statistically different between patients with benign and malignant adenopathy included the duration of adenopathy (P = .43), the presence of fever (P = .36), cough (P = .14), splenomegaly (P = .93), skin involvement (P = .39), tenderness (P = .49), and bilateral adenopathy (P = .39). Fluctuance was associated with benign adenopathy (P < .04). CONCLUSIONS: The risk of malignancy increased with increasing size and number of sites of adenopathy and age. Other significant predictors of malignancy included supraclavicular location, an abnormal chest x-ray, and fixed nodes. These data may be used to supplement clinical judgment to predict the risk of malignancy.

Child↗
PubMed1999

The utility of technetium 99m pertechnetate scintigraphy in the evaluation of patients with Meckel's diverticulum.

PURPOSE: The aim of this study was to assess the utility of technetium (Tc) 99m pertechnetate scintigraphy in the diagnostic workup of the pediatric patient with gastrointestinal (GI) bleeding and a suspected Meckel's diverticulum. METHODS: The charts of 235 consecutive patients evaluated with a Meckel's scan (n = 165) or with the discharge diagnosis of Meckel's diverticulum (n = 70) between January 1975 and October 1997 were reviewed for presenting symptoms, bleeding characteristics, diagnostic studies and pathological diagnosis. Those patients with lower GI bleeding and a serum hemoglobin level less than 11.0 g/dL who underwent a 99mTc pertechnetate scan (n = 43) were assessed for utility of the scan. RESULTS: In all patients the Meckel's scan had a positive and negative predictive value of 0.93. However, in patients with lower GI bleeding and a hemoglobin less than 11.0 g/dL the Meckel's scan had a sensitivity of 0.60, a positive predictive value of 1.0, a specificity of 0.96, but only a negative predictive value of 0.74. As such, the probability that a child who presents with GI bleeding and a serum hemoglobin less than 11 g/dL will have a Meckel's diverticulum despite a negative Meckel's scan of 0.26. We further evaluated the eight patients with a false-negative scan: ectopic gastric mucosa was present on pathological examination in all eight patients. Pentagastrin stimulation was performed at the time of scintigraphic study in three of eight. Six of these eight patients had duplicate scans that also were negative. Patients with a false-negative (FN) scan had significantly increased hospital charges when compared with those with a true positive (TP) scan (TP = $5012 +/- 1992; FN = $8554 +/- 1506; P = .0001). Clinical suspicion had a major effect on the decision-making process in these patients independent of the results of the Meckel's scan, and all eight patients ultimately underwent exploratory laparoscopy-laparotomy with Meckel's diverticulectomy despite the scan results. CONCLUSIONS: The relatively low negative predictive value of the Meckel's scan may result in the need for operative evaluation despite the scan data. As such, the contribution of the scan to clinical decision making is low. These findings suggest that exploratory laparotomy or laparoscopy may be indicated instead of scintigraphic scanning in the assessment of the anemic (hemoglobin less than 11 g/dL) pediatric patient with lower GI bleeding, especially in patients in whom a high suspicion for a bleeding Meckel's diverticulum exists.

Adolescent↗
PubMed1999

Prenatal diagnosis of congenital cystic adenomatoid malformation and its postnatal presentation, surgical indications, and natural history.

BACKGROUND/PURPOSE: Regression of a cystic adenomatoid malformation (CAM) in a fetus is well described. Little, however, is known about the postnatal course of these infants. This study attempts to correlate the prenatal course of CAMs with postnatal symptoms, radiological manifestations, and need for surgery. METHODS: The clinical course of patients with a CAM diagnosed prenatally were retrospectively reviewed. Inclusion in the study required a prenatal ultrasound scan documenting a CAM. RESULTS: Over 10 years, 14 patients with a CAM were diagnosed prenatally. Six (43%) showed a partial in utero regression. Four patients were symptomatic at birth and underwent a resection as newborns. Ten patients were asymptomatic at birth, and eight of these had normal chest x-rays. Elective resection has been performed in 3 of these 10, and two additional children are scheduled to undergo an excision near 1 year of age. The remaining five patients have undergone follow-up nonoperatively for a mean of 36 +/- 15 months. Of the seven asymptomatic patients not undergoing immediate surgery, only one has shown a slight postnatal regression, despite five of these showing regression in utero. None have become symptomatic. CONCLUSIONS: The results suggest that regression of a CAM on prenatal ultrasound scan is common, but this process does not continue after birth. A normal chest x-ray does not indicate complete regression of a CAM; a computed tomography (CT) scan is required to evaluate such patients, and will generally demonstrate a CAM. Asymptomatic patients with a CAM may be followed up nonoperatively with no apparent adverse effects. The decision and timing of an excision in an asymptomatic patient remains controversial among pediatric surgeons.

Cystic Adenomatoid Malformation of Lung, Congenita↗
PubMed1999

Respiratory failure: current status of experimental therapies.

A number of advances in the treatment of infants and children with respiratory failure have been investigated in the laboratory with translation to clinical practice. Investigators have recognized that application of high ventilating pressures and failure to apply adequate levels of positive end-expiratory pressure (PEEP) can inflict injury to the already failing lung. Other interventions such as prone positioning and application of new ventilating strategies such as proportional assist ventilation (PAV), inverse ratio ventilation (IRV), high frequency ventilation, liquid ventilation, and intratracheal pulmonary ventilation (ITPV), continue to be developed and explored. Administration of inhaled nitric oxide (iNO) may improve pulmonary physiology and gas exchange in patients with respiratory insufficiency. Finally, the technique of extracorporeal life support (ECLS) is being simplified and refined. This report summarizes the status of these advances and describes the basic science and clinical research that brought them to clinical application.

Algorithms↗
PubMed1999

Specialty networking in pediatric surgery: a paradigm for the future of academic surgery.

OBJECTIVE: To review retrospectively a 4-year experience with pediatric surgical networking at a major academic medical center in the Midwest. BACKGROUND: The growth of managed care in the United States during the past decade has had a major impact on the practice of medicine in general, but especially on academic medicine. In some academic medical centers, the loss of market share has not only affected clinical activity but has also compromised the educational and research missions of these institutions. METHODS: At the authors' institution, a networking strategy in pediatric surgery was established in 1993 and implemented on July 1, 1994. In 1994, one new satellite practice was established; over the next 4 years, four additional practices were added, including one in another state. To assess the impact on financial status, clinical activity, education, and academic productivity, the following parameters were analyzed: gross and net revenue, surgical cases, clinic visits, ranking of the pediatric surgery residency, publications, grant support, and development and endowment funds. RESULTS: Gross and net revenue increased from $3,273,000 and $302,000 in 1993 to $10,087,000 and $2,826,000, respectively, in 1998. Surgical cases and clinic visits increased from 1240 and 3751 in 1993 to 5872 and 11,604, respectively, in 1998. At the medical center's children's hospital, surgical cases and clinic visits increased from 1240 and 3751 to 2592 and 4729 during the same time period. During this 4-year period, the faculty increased from 4 to 11. Since 1997, the National Resident Matching Program has provided data on how pediatric surgery residency candidates ranked a training program. In 1997, this program received the second-most one to five rankings; in 1998, it tied for first. This exceeds the faculty's perception of previous years' rankings. Publications increased from 26 in 1993 to a peak number of 62 in 1996; in 1997 and 1998 the publications were 48 and 37, respectively. External grant support increased from $139,882 in 1993 to a total of $6,109,971 in 1998. Development and endowment funds increased from $103,559 in 1993 to $2,702,2777 in 1998. CONCLUSIONS: Pediatric surgical networking at the authors' institution has had a markedly positive impact on finances, clinical activity, education, and academic productivity during a 4-year period. The residency training program appears to have improved in popularity among candidates, probably because of the increased referral of complex cases to the medical center from the various networking satellites. External grant support and basic laboratory research significantly increased, most likely because of the greater number of faculty with protected time for research recruited. Development and endowment funds dramatically grew because of the excellent fiscal health of the pediatric surgical program. This experience may serve as a model for other academic surgical specialties.

Academic Medical Centers↗
PubMed1999

Prolonged partial liquid ventilation in spontaneously breathing awake animals.

OBJECTIVE: To date, studies of partial liquid ventilation (PLV) have examined its effects acutely in anesthetized and mechanically ventilated subjects. We set out to develop a model of prolonged PLV in awake, spontaneously breathing animals. DESIGN: Animal case series SETTING: Cardiopulmonary physiology laboratory. SUBJECTS: Fifteen New Zealand white rabbits (3.2+/-0.39 kg). INTERVENTIONS: Animals were anesthetized and instrumented with a novel technique allowing percutaneously assisted placement of an intratracheal catheter with a subcutaneously tunneled externalized free end. After anesthetic recovery, PLV was performed in spontaneously breathing unsedated animals. MEASUREMENTS AND MAIN RESULTS: Evaporative losses were determined using a single 10 mL/kg perflubron dose (n = 5); hourly radiographs were obtained until residual perflubron was minimal. For prolonged PLV (n = 10), a 10-mL/kg initial perflubron dose was followed every 4 hrs with 5-mL/kg supplements. Radiographs were obtained immediately before and after perflubron administration and were scored (0-5) by a radiologist blinded to dosing regimen and time interval. Data were analyzed with ANOVA and Student's t-test with correction for multiple comparisons. Initial filling was nearly complete (score = 4.8+/-0.42); lungs were maintained approximately half-filled through 4 hrs (score = 2.53+/-0.71). By 6 hrs, the majority of perflubron had evaporated (score = 1.75+/-0.53). Over 24 hrs, radiographs documented continuous perflubron exposure (postffill = 4.53+/-0.64, prefill = 3.40+/-0.71, average = 3.97+/-0.43); scores were comparatively higher after filling (after = 4.53+/-0.64, before = 3.4+/-0.71, p< .001). Left and right lung volumes were equivalent (left = 4.06+/-0.47, right = 3.89+/-0.39, p = .027). All animals survived the 24 hrs of PLV. CONCLUSIONS: Percutaneously assisted intratracheal cannulation with catheter exteriorization permits prolonged PLV in spontaneously breathing, unsedated animals. Continuous perfluorocarbon exposure with this method is reproducible, consistent, and well tolerated for 24 hrs in uninjured animals.

Analysis of Variance↗
PubMed1999

Extracorporeal life support in pulmonary failure after trauma.

OBJECTIVE: To present a series of 30 adult trauma patients who received extracorporeal life support (ECLS) for pulmonary failure and to retrospectively review variables related to their outcome. METHODS: In a Level I trauma center between 1989 and 1997, ECLS with continuous heparin anticoagulation was instituted in 30 injured patients older than 15 years. Indication was for an estimated mortality risk greater than 80%, defined by a PaO2: FIO2 ratio less than 100 on 100% FIO2, despite pressure-mode inverse ratio ventilation, optimal positive end-expiratory pressure, reasonable diuresis, transfusion, and prone positioning. Retrospective analysis included demographic information (age, gender, Injury Severity Score, injury mechanism), pulmonary physiologic and gas-exchange values (pre-ECLS ventilator days [VENT days], PaO2:FIO2 ratio, mixed venous oxygen saturation [SvO2], and blood gas), pre-ECLS cardiopulmonary resuscitation, complications of ECLS (bleeding, circuit problems, leukopenia, infection, pneumothorax, acute renal failure, and pressors on ECLS), and survival. RESULTS: The subjects were 26.3+/-2.1 years old (range, 15-59 years), 50% male, and had blunt injury in 83.3%. Pulmonary recovery sufficient to wean the patient from ECLS occurred in 17 patients (56.7%), and 50% survived to discharge. Fewer VENT days and more normal SvO2 were associated with survival. The presence of acute renal failure and the need for venoarterial support (venoarterial bypass) were more common in the patients who died. Bleeding complications (requiring intervention or additional transfusion) occurred in 58.6% of patients and were not associated with mortality. Early use of ECLS (VENT days < or = 5) was associated with an odds ratio of 7.2 for survival. Fewer VENT days was independently associated with survival in a logistic regression model (p = 0.029). Age, Injury Severity Score, and PaO2:FIO2 ratio were not related to outcome. CONCLUSION: ECLS has been safely used in adult trauma patients with multiple injuries and severe pulmonary failure. In our series, early implementation of ECLS was associated with improved survival. Although this may represent selection bias for less intractable forms of acute respiratory distress syndrome, it is our experience that early institution of ECLS may lead to improved oxygen delivery, diminished ventilator-induced lung injury, and improved survival.

Adolescent↗
PubMed1999

Advances in ventilatory support of the pediatric surgical patient.

Severe respiratory failure in newborn and pediatric patients is associated with significant morbidity and mortality. Basic science laboratory investigation has led to advances both in our understanding of ventilator-induced lung injury and in optimizing the supportive use of conventional ventilation strategies. Over the past few years, progress has been made in alternative therapies for ventilating both children and adults with severe respiratory failure. This review focuses on recent laboratory and clinical data detailing the techniques of permissive hypercapnia, high frequency oscillatory ventilation, inhaled nitric oxide, intratracheal pulmonary ventilation, and liquid ventilation. Some of these modalities are becoming commonplace, and others may have much to offer the clinician if their benefit is clearly demonstrated in future clinical trials.

Child↗
PubMed1999

Extracorporeal resuscitation of cardiac arrest.

OBJECTIVE: Extracorporeal support of heart and lung function (venoarterial perfusion) during cardiac arrest (ECPR) has been advocated as a means of improving survival following cardiac arrest. The authors retrospectively reviewed their institution's seven-year experience with this intervention. METHODS: Emergency department patients and inpatients in cardiac arrest or immediately postarrest were considered candidates. ECPR was instituted using venoarterial bypass and was continued until patients regained sufficient cardiopulmonary function to allow weaning from the device or until their condition was deemed irrecoverable. RESULTS: ECPR was attempted in 25 patients and successfully instituted in 21. Four patients (16%) were converted from ECPR to ventricular assist devices, two of whom survived and await transplantation. Seven additional patients were discharged from the hospital, resulting in an overall survival of 36%. Because none of the children treated survived, there was a trend toward higher age among survivors (survivors 40 +/- 14 yr, nonsurvivors 33 +/- 15 yr, p = 0.29). The duration of conventional CPR was shorter among survivors (survivors 21 +/- 16 min, nonsurvivors 43 +/- 32 min, p = 0.04), as was the duration of extracorporeal support (survivors 44 +/- 21 hr, nonsurvivors 87 +/- 96 hr, p = 0.18). Survival was seen only in patients whose conditions were amenable to a definitive therapeutic intervention, particularly cardiac arrest due to respiratory or pulmonary embolic disease. While four of the five patients treated in the ED were successfully supported, none survived to discharge. CONCLUSION: In select patients with reversible disease, extracorporeal CPR can be used to successfully treat cardiac arrest. Further investigation into its most appropriate application is warranted.

Adolescent↗
PubMed1999

Venovenous extracorporeal life support via percutaneous cannulation in 94 patients.

STUDY OBJECTIVE: The objective of this study was to demonstrate the safety and utility of a method of percutaneous access for cannulation of adult patients for venovenous extracorporeal life support (ECLS). DESIGN: A retrospective review of a patient series. SETTING: A surgical ICU at a university teaching hospital. PATIENTS: The study group consisted of 94 adults > 17 years old with respiratory failure who were placed on venovenous ECLS by means of percutaneous cannulation. INTERVENTIONS: The cannulation of the internal jugular and femoral veins (FVs) using the Seldinger technique for venovenous ECLS. MEASUREMENTS AND RESULTS: Between May 1992 and November 1997, we performed percutaneous cannulation for venovenous ECLS in 94 adult patients with respiratory failure. The mean (+/- SD) age was 36.1+/-12.7 years old (range, 17 to 65 years). The mean (+/-SD) weight was 80.7+/-22.3 kg (range, 36 to 156 kg). The right internal jugular vein (RIJV) was used for venous drainage access in all but four cases. The right FV (n = 86), the left FV (n = 3), or the RIJV (n = 4) was utilized for venous reinfusion. The maximum blood flow (+/-SD) during ECLS was 57.6+/-17.5 mL/kg/min (range, 22.4 to 127.8 mL/kg/min), with a postmembrane outlet pressure (+/-SD) of 146+/-43 mm Hg (range, 56 to 258 mm Hg) at the maximum flow rate. There were 11 unsuccessful percutaneous cannulation attempts. In three patients (3%), the complications consisted of arterial injury requiring operative cutdown and repair. In six patients (6%), cannula-site bleeding required pursestring suture reinforcement of the cannula site. One patient died from the perforation of the superior vena cava during cannulation. CONCLUSIONS: Based on these data, we conclude that percutaneous cannulation may be utilized to provide venovenous ECLS in adults.

Adult↗
PubMed1998

Liquid ventilation in an infant with pulmonary alveolar proteinosis.

Partial liquid ventilation (PLV) has been applied in various pulmonary diseases. We describe the use of partial liquid ventilation as a lavage method following normal saline (NS) lavage in an infant with pulmonary alveolar proteinosis (PAP) and severe hypoxemia. A 6 weeks old 3.4 kg former 36 weeks gestation boy on supplemental oxygen was transferred to our NICU with persistent tachypnea, dry cough, and increasing oxygen requirements. A lingular open lung biopsy revealed PAP. He developed progressive respiratory failure requiring ventilatory support, necessitating conventional NS lavage, followed by lung lavage with perflubron (LiquiVent; Alliance Pharmaceutical Corp. and Hoechst Marion Roussel) while on venovenous extracorporeal life support (ECLS). Lung lavage with NS and perflubron yielded minimal cloudy effluent. Gas exchange and pulmonary function deteriorated following NS lavage and attempts to discontinue ECLS were poorly tolerated. In contrast, tidal volume, PaO2, and pulmonary compliance increased after PLV, while the (A-a) D(O2) decreased to a point where ECLS was no longer required. Once perflubron was added repeatedly to the ventilator circuit to correct for evaporation over the 4 days of PLV. Cardiovascular status remained stable for several days; however, eventually he required reinitiation of ECLS and more mechanical ventilatory support with each trial off ECLS. He was maintained on high pressures and FiO2 without any possibility to wean him from mechanical ventilation. Life support was withdrawn 1 month after admission. The survival from PAP in infants remains dismal, even with total lung NS lavage. While both NS and perflubron lavage in this patient were not effective in removing the proteinaceous alveolar debris, PLV following NS lavage was associated with an improvement in gas exchange and lung compliance.

Bronchoalveolar Lavage↗
PubMed1998

The role of ultrasonography in the diagnosis of pyloric stenosis: a decision analysis.

BACKGROUND/PURPOSE: The appropriate role for ultrasonography (US) as a replacement for the upper gastrointestinal series (UGI) in vomiting infants remains undefined. The authors have used decision analysis techniques to determine whether the use of ultrasonography as an initial screen in vomiting infants is cost effective when compared with the UGI as the only study. METHODS: Two diagnostic strategies were compared: 1) UGI alone and 2) ultrasonography followed by an UGI series in 50% of cases when ultrasonography scan was negative for pyloric stenosis. The test sensitivity (US, 0.9; UGI, 1.0) and test specificity (US, 1.0; UGI, 1.0) and the incidence of pyloric stenosis among vomiting infants presenting to the community pediatrician (0.30) or after a negative examination by an experienced examiner (0.02 to 0.18) were obtained from a review of the literature. The relative charges for ultrasonography and UGI were obtained from a national survey from which the cost ratio of US to UGI was estimated to range from 0.67 to 1.81 with a median of 1.06. RESULTS: Under these baseline assumptions, UGI only was the preferred strategy. The results of the decision analysis were sensitive to, or dependent on, assumptions made regarding the incidence of pyloric stenosis, the US to UGI cost ratio, the sensitivity of the US, and the proportion of patients that proceed to UGI when the US scan was negative for pyloric stenosis. When at least 50% of patients whose US scan was negative for pyloric stenosis proceeded to a UGI, UGI remained the preferred strategy for all cost ratios examined (0.6 to 1.7). Even when no patients proceeded to UGI, the cost ratio of US to UGI had to be less than 0.7 under the typical incidence (0.30) of pyloric stenosis among vomiting infants presenting to the community pediatrician for US to be cost effective. Finally, only UGI was indicated when an olive was not appreciated by an experienced examiner. CONCLUSION: Under assumptions that fit most clinically relevant circumstances, the UGI as the initial study is the most cost-effective radiological diagnostic test in the evaluation of the vomiting infant.

Contrast Media↗
PubMed1998

Immediate and long-term results of surgical management of low imperforate anus in girls.

BACKGROUND: The majority of girls with imperforate anus are reported to have a malformation of the low variety. Despite this, much of the literature has focused on the more complex, high lesions. METHODS: This study reviews our experience with 44 girls with low imperforate anus from a 22-year period. RESULTS: The incidence of associated anomalies was 61%, which is higher than generally reported. All patients in the study had anal fistulae. Fifty-seven percent had perineal fistulae, 23% had fourchette fistulae, and 20% had vestibular fistulae. Cutback anoplasty was performed in 55%, Potts transfer anoplasty was used in 27%, and 18% of patients were treated with either limited posterior sagittal anorectoplasty or anterior sagittal anorectoplasty. Surgical complications were uncommon. Long-term follow-up was carried out by telephone survey. This showed 89% of the girls to be successfully toilet trained. However, 47% of patients experience at least occasional soilage or episodic fecal incontinence. CONCLUSIONS: Low imperforate anus can be successfully treated using a variety of procedures without colostomy. Most girls with low imperforate anus are successfully toilet trained, but problems with continence persist in a significant number of these patients.

Anus, Imperforate↗
PubMed1998

Percutaneous access for venovenous extracorporeal life support in neonates.

BACKGROUND: Although percutaneous cannulation has been previously described in adult and pediatric patients older than 3 years, its use in neonates for venovenous extracorporeal life support (ECLS) has not been previously described. METHODS: Twenty neonates of weight 3.4 +/- 0.6 kg (range, 2.3 to 4.9 kg.) with severe respiratory failure (meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, sepsis) were managed with double-lumen venovenous ECLS. Percutaneous access via the right internal jugular (RIJ) vein with a 12F (n = 13) or 15F (n = 7) double-lumen ECLS cannula was obtained via a modified Seldinger technique. RIJ access was specifically obtained 2 to 3 cm above the clavicle with a 21-gauge needle and a 0.018-in guide wire followed by a technique that allowed insertion of the larger cannula guide wire. Decannulation simply involved removal of the cannula with hemostasis obtained by direct pressure. RESULTS: Percutaneous cannulation was performed without difficulty in 11 infants. Conversion to an open technique for cannula placement was required in four patients early in our experience because percutaneous access to the RIJ with the 0.018-inch guide wire could not be achieved, and in one neonate because the 15F cannula could not be advanced into the RIJ and resulted in laceration of the vein. Inability to achieve RIJ access also led to use of an "exposure-assisted" percutaneous procedure in four patients later in our experience. Complications included a pneumothorax identified on chest radiograph 18 hours after cannulation in one infant and partial thrombotic occlusion of the cannula requiring a change over a guide wire in another. There were no problems associated with decannulation. CONCLUSIONS: This is the first description of percutaneous cannulation in neonates for venovenous ECLS. In the authors' early experience, percutaneous access using a 12F double lumen venovenous cannula may be efficiently performed especially in patients >3.0 kg in weight and has the potential for simplifying and reducing the cost of the ECLS technique.

Catheterization, Central Venous↗
PubMed1998

Current surgical management of congenital diaphragmatic hernia: a report from the Congenital Diaphragmatic Hernia Study Group.

BACKGROUND: Repair of congenital diaphragmatic hernia (CDH) has changed from an emergent procedure to a delayed procedure in the last decade. Many other aspects of management have also evolved since the first successful repair. However, most reports are from single institutions. The lack of a large multicenter database has hampered progress in the management of congenital diaphragmatic hernia (CDH) and makes determination of the current standard difficult. METHODS: The CDH study group was formed in 1995 to collect data from multiple institutions in North America, Europe, and Australia. Participating centers completed a registry form on all live-born infants with CDH during 1995 and 1996. Demographic information, data about surgical management, and outcome were collected for all patients. RESULTS: Sixty-two centers participated, with 461 patients entered. Overall survival was 280 of 442 patients (63%) where survival was recorded. The defect was left-sided in 78%, right-sided in 21%, and bilateral in 1%. A subcostal approach was used in 91% of patients, with pleural drainage used in 76%. A patch of some kind was used in just over half (51%) of the patients, with polytetrafluoroethylene being the most commonly used material (81%) in those patients with a patch. The mean surgical time was 102 minutes, with an average blood loss of 14 mL (range, 0 to 500 mL). The overwhelming majority of patients underwent repair between 6:00 AM and 6:00 PM (289 of 329, 88%). Nineteen percent of patients had surgical repair on extracorporeal membrane oxygenation (ECMO) at a mean time of 170 hours into the ECMO course (range, 10 to 593 hours). The mean age at surgery in patients not treated with ECMO was 73 hours (range, 1 to 445 hours). CONCLUSIONS: The multicenter nature of this report makes it a snapshot of current management. The data would indicate that prosthetic patching of the defect has become common, that after-hours repair is infrequent, and that delayed surgical repair has become the preferred approach in many centers. Furthermore, the mean survival rate of 63% indicates that despite decades of individual effort, the CDH problem is far from solved. This highlights the need for a centralized database and cooperative multicenter studies in the future.

Chi-Square Distribution↗
PubMed1998

The lateral approach for open splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS. METHODS: Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle. RESULTS: All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity. CONCLUSIONS: Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.

Adolescent↗
PubMed1998

A prospective comparison of atrio-femoral and femoro-atrial flow in adult venovenous extracorporeal life support.

INTRODUCTION: In the United States, venovenous extracorporeal life support has traditionally been performed with atrial drainage and femoral reinfusion (atrio-femoral flow). Although flow reversal (femoro-atrial flow) may alter recirculation and extracorporeal flow, no direct comparison of these 2 modes has been undertaken. OBJECTIVE: Our goal was to prospectively compare atrio-femoral and femoro-atrial flow in adult venovenous extracorporeal life support for respiratory failure. METHODS: A modified bridge enabling conversion between atrio-femoral and femoro-atrial flow was incorporated in the extracorporeal circuit. Bypass was initiated in the direction that provided the highest pulmonary arterial mixed venous oxygen saturation, and the following measurements were taken: (1) maximum extracorporeal flow, (2) highest achievable pulmonary arterial mixed venous oxygen saturation, and (3) flow required to maintain the same pulmonary arterial mixed venous oxygen saturation in both directions. Flow direction was then reversed, and the measurements were repeated. Data were compared with paired t tests and are presented as mean +/- standard deviation. RESULTS: Ten patients were studied, and 9 were included in the data analysis. Femoro-atrial bypass provided (1) higher maximal extracorporeal flow (femoro-atrial flow = 55.6 +/- 9.8 mL/kg per minute, atrio-femoral flow = 51.1 +/- 11.1 mL/kg per minute; P = .04) and (2) higher pulmonary arterial mixed venous oxygen saturation (femoroatrial flow = 89.9% +/- 6.6%, atrio-femoral flow = 83.2% +/- 4.2%; P = .006); (3) furthermore, it required less flow to maintain an equivalent pulmonary arterial mixed venous oxygen saturation (femoro-atrial flow = 37.0 +/- 12.2 mL/kg per minute, atrio-femoral flow = 46.4 +/- 8.8 mL/kg per minute; P = .04). CONCLUSIONS: During venovenous extracorporeal life support, femoro-atrial bypass provided higher maximal extracorporeal flow, higher pulmonary arterial mixed venous oxygen saturation, and required comparatively less flow to maintain an equivalent mixed venous oxygen saturation than did atrio-femoral bypass.

Adult↗