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PubMed2000

Balloon arterioplasty of recurrent coarctation after the modified Norwood procedure in infants.

Coarctation of the reconstructed aorta after the modified Norwood procedure for hypoplastic left heart syndrome is a relatively common occurrence that can have significant adverse effects. From 1992-98, 65 infants with hypoplastic left heart syndrome or variants thereof underwent a modified Norwood procedure. Of the 50 survivors of Stage I palliation, 10 (20%) were subsequently diagnosed with clinically significant obstruction of the aortic arch at a median age of 5.1 months. Eight of these patients underwent coarctation balloon arterioplasty. All 8 patients underwent successful dilation of the coarctation, with a decrease in the pressure gradient from 43+/-20 to 4+/-5 mm Hg and an increase in aortic diameter at the site of obstruction from 3.5+/-0.5 to 7.0+/-1.0 mm (both P<0.001). There was also a significant increase in lower extremity systolic blood pressure. Although there was no immediate increase in cardiac output after dilation in most patients, ventricular function was improved in 3 patients within 24-48 hr of the procedure and in all but 2 at the most recent follow-up (median 2 years). Two patients developed bradycardia during wire placement that required cardiopulmonary resuscitation. Two others died suddenly during the follow-up period. All surviving patients have undergone subsequent palliative procedures; none have required repeat intervention for arch obstruction. We found a 20% incidence of coarctation in survivors of the modified Norwood procedure. Balloon arterioplasty is effective in relieving this obstruction, and should be carried out promptly upon diagnosis to minimize its deleterious effects on ventricular function. Balloon dilation, however, should be considered a high-risk procedure in these fragile infants, and special attention must be given to cardiovascular support.

Anastomosis, Surgical↗
PubMed1995

Gasless video-assisted reversal of Hartmann's procedure.

More than 60% of patients who are submitted to Hartmann's procedure refuse to undergo reversal. This procedure is in fact a major undertaking associated with significantly mortality and morbidity rates. The authors suggest a minimally invasive approach without pneumoperitoneum. A consecutive series of four male patients, average age 64 years, underwent laparoscopic assisted reversal of Hartmann's procedure in our department. The procedure was performed for intestinal malignant occlusion in two cases and for perforated diverticulitis in the other two. Mobilization was nearly immediate and incisional pain almost absent; peristalsis restarted after 36-48 h. Finally, the patients were discharged on day 6. Neither mortality nor morbidity occurred in the 8-month follow-up period. The authors conclude that this new laparoscopic procedure may lead to shorter hospital stays and increased acceptance by patients, while maintaining the same safety of the traditional open procedure.

Colon, Sigmoid↗
PubMed2003

Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse.

The aim of the study was to determine the long-term results of Burch procedures combined with vault prolapse repair by abdominal sacrocolpopexy. Between 1986 and 1997 82 women (mean age 46.0 years, range 27-79) underwent sacrocolpopexy combined with a Burch procedure. All patients presented with urinary incontinence and vault prolapse. The surgery consisted of a Burch procedure using non-absorbable suture material, and abdominal sacrocolpopexy with a non-absorbable mesh. The mesh was placed anteriorly and posteriorly in 66 cases, posteriorly (rectovaginal) in 12, and anteriorly (vesicovaginal) in 4. Additional procedures included hysterectomy (34 cases), enterocele repair (79 cases), and posterior repair with perineorrhaphy (65 cases). Failure was defined as the presence of persistent or worsened postoperative stress urinary incontinence (SUI). At a mean follow-up of 86 months (range 24-133) 34% (28/82) of patients were dry, and another 46% (38/82) were improved compared to their preoperative status. The postoperative SUI rate (persistent, worsened) after the placement of a single anterior mesh (4 failures out of 4) was higher than the postoperative SUI rate after combined meshes (41 failures out of 66) (log rank P = 0.05). All the patients with a history of prior surgery had worsened or persistent stress urinary incontinence (7/7), but 63% (47/75) of those with no prior surgery for stress urinary incontinence had worsened or persistent stress urinary incontinence (log rank P = 0.01). One case of recurrent rectocele was observed (after 20 months) and treated by transvaginal Richter sacrospinous fixation. At a mean follow up of 7 years, the Burch procedure combined with abdominal sacrocolpopexy appears to be less effective than previously published long-term results for the Burch procedure alone.

Adult↗
PubMedDate not supplied

Misconceptions about mandible reduction procedures.

Mandible reduction procedures are currently very popular in Asian countries. But many misconceptions or differences in concepts about these procedures still exist, mainly because of preconceived ideas and restriction in communication. The author reviewed articles and found some misconceptions about these procedures. Also, the author added some opinions regarding new ideas about these procedures (i.e., minimal incision technique and botulinum toxin), as well as logical backgrounds of associated concepts. The intraoral approach is the safest and most effective procedure. The sagittal split ostectomy is the most important procedure for mandible reduction.

Asian People↗
PubMed2003

Endosurgical procedures for pediatric solid tumors.

The aim of this study was to evaluate the advantages and complications of endosurgical procedures for benign and malignant pediatric solid tumors. Endosurgical techniques of biopsy and excision were used for diagnosis and treatment of solid tumors, respectively. Since July 1997, a total of 24 biopsies and 24 excisions have been performed laparoscopically for neuroblastoma ( n=24), ovarian solid tumors ( n=10) and other tumors. Seventeen biopsies and six excisions were performed for abdominal neuroblastoma, while ten excisions were performed for ovarian tumor. In these patients, the length of the operation, blood loss, time to start postoperative feeding, time to start postoperative chemotherapy and length of hospital stay were evaluated and compared to the those of the open surgery group. Furthermore, intra- and postoperative complications were analyzed in all patients of both groups. The length of the hospital stay and time to start postoperative feeding were significantly shorter in the group of patients who underwent endosurgical procedures for either abdominal neuroblastoma or ovarian tumor when compared to the open procedure group. The time to start postoperative chemotherapy was shorter only in the abdominal neuroblastoma group. The procedure for two patients undergoing endosurgical tumor excision had to be converted to open surgery due to large tumor size. Two weeks after thoracoscopic excision of a dumb bell-type neurofibroma, one patient underwent open repair of the dura mater because of leakage of cerebrospinal fluid. There were no port-site recurrences in any tumor types. Endosurgical procedures for solid tumors are effective and minimally invasive. However, better indicators are needed for their implementation in order to prevent complications and subsequent conversions to open procedures.

Abdominal Neoplasms↗
PubMed2003

Current status of an antireflux procedure in laparoscopic Heller myotomy.

BACKGROUND: Persistent dysphagia and postoperative gastroesophageal reflux (GER) are the most cited reasons for surgical failure of laparoscopic Heller myotomy. Adding an antireflux procedure to Heller myotomy has been proposed to prevent reflux. We hypothesized that an antireflux procedure added to laparoscopic Heller myotomy has little effect on preventing the symptoms or long-term sequelae of GER in achalasia patients. METHODS: We performed a meta-analysis of studies on human subjects reported in the English language literature from 1991 to 2001 years. RESULTS: An antireflux procedure accompanied laparoscopic myotomy in 15 studies with 532 patients. In 6 studies of 69 patients, no antireflux procedure was added to laparoscopic myotomy. Follow-up was available on 489 patients (92%) with partial fundoplication. The rate of GER diagnosed in pH studies was 7.9% (18 of 228 patients studied), whereas only 5.9% of patients experienced symptoms of GER (29 of 489 patients followed). Of the 69 patients without fundoplication, 47 (68%) were available for follow-up. Forty patients (85%) were studied with pH monitoring postoperatively, with 4 (10%) demonstrating reflux. Six (13%) of 47 patients had symptoms of GER. The difference in the rate of GER diagnosed in postmyotomy pH studies in wrapped and nonwrapped patients was not significant (7.9 vs 10%, respectively; p = 0.75). There was also no significant difference in the incidence of postmyotomy GER symptoms in wrapped and nonwrapped patients (5.9 vs 13% respectively; p = 0.12). CONCLUSIONS: Reflux is not necessarily eliminated with the addition of a partial fundoplication. Based on the published data, recommendations cannot be made regarding the efficacy of adding an antireflux procedure to laparoscopic Heller myotomy. Prospective randomized study is needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Digestive System Surgical Procedures↗
PubMed2002

A decade of decline: an analysis of Medicare reimbursement for vascular surgical procedures.

Despite inflation and a robust economy, standard Medicare reimbursements for vascular surgical procedures have progressively declined. The objective of this analysis was to quantitatively and objectively evaluate the decline of vascular surgical reimbursement over the past decade. In this study, data for the analysis of specific vascular surgical procedures was obtained from the National Center for Health Statistics-National Hospital Discharge Survey (NCHS-NHDS) for all vascular procedures as reported by ICD-9-CM codes. The average Medicare reimbursement for each of the specified procedures for 1990 was compared to that of 2001 and the percent change in average reimbursement over this period was calculated. Comparisons between 1990 and 2001 dollar amounts were made after correction for inflation using the consumer price index. This correction factor allows for the calculation of the actual percentage reduction in "real dollars" that is reflected in buying power. We found significant decreases in Medicare reimbursement for each of the vascular procedures included in this analysis. Despite national economic prosperity, there was an average 41% decrease in the buying power per case for vascular surgical procedures over the past decade. We feel that these reductions in reimbursement are overzealous and need to be reexamined.

Aged↗
PubMed2004

Emergency operation in carcinomas of the left colon: value of Hartmann's procedure.

BACKGROUND: Colonic resection according to the procedure by Hartmann is considered a fast and safe surgical intervention, which has been used for years, in particular, in emergency situations. METHODS: Using data of a prospective multicentre study on the operative treatment of colorectal carcinoma over the time period from 1 January 2000 to 31 December 2002, the value of Hartmann's procedure was investigated in carcinoma of the left colon (n=8825) compared with alternative surgical options under emergency circumstances. The significant impact of independent variables on the type of the selected approach was determined by means of logistic regression. RESULTS: While in total 422 primary Hartmann's procedures (4.8%) were executed under curative intention, 213 (50.5%) of those were carried out in emergency situations. Hartmann's procedure was beneficial in cases with tumour-associated obstruction and perforation of the left colon as it resulted in the lowest mortality (7.5%) of the radical operations. Even under palliative intention, Hartmann's procedure was preferred at the left colon but led to a postoperative mortality (32.7%) very similar to that in creation of a colostoma (33.3%) or segmental colonic resection (38.9%). CONCLUSIONS: Hartmann's procedure has been widely accepted as a curative intervention in emergency cases (oncosurgically adequate R0 resection) for the carcinoma of the left colon. Because of the high postoperative morbidity and mortality in emergency situations with only palliative options (R0 resection not possible), alternative endoscopic treatment should be considered more frequently.

Adenocarcinoma↗
PubMed1994

Comparison of the hormonal response after bidirectional Glenn and Fontan procedures.

Fluid retention is a frequent complication after the bidirectional Glenn and Fontan procedures. It was our hypothesis that this fluid retention may have a hormonal basis. To test this hypothesis, we made serial determinations of antidiuretic hormone, cortisol, aldosterone, angiotensin, and renin before and after operation in patients undergoing a bidirectional Glenn (n = 15) or Fontan (n = 18) procedure. Patients undergoing a bidirectional Glenn procedure had elevations in antidiuretic hormone, cortisol, and aldosterone immediately after operation. However, none of the hormonal elevations persisted by the fifth postoperative day. In contrast, patients undergoing a Fontan procedure had elevations in antidiuretic hormone, cortisol, aldosterone, renin, and angiotensin II in the immediate postoperative period. Five days postoperatively, the renin and angiotensin II levels remained elevated compared with the preoperative values. The data demonstrate that patients undergoing a bidirectional Glenn procedure and those undergoing a Fontan procedure have different patterns of hormonal response. These results suggest that hormonal factors may contribute to fluid retention after these operations.

Aldosterone↗
PubMed1995

Effect of late postoperative atrial septal defect closure on hemodynamic function in patients with a Lateral tunnel Fontan procedure.

OBJECTIVES: The aim of this study was to evaluate prospectively the effect of late atrial septal defect closure on cardiac output and oxygen delivery in patients who have undergone the Fontan procedure. BACKGROUND: An adjustable atrial septal defect is incorporated in patients undergoing the Fontan procedure who have increased pulmonary vascular resistance or poor ventricular function, or both. After the Fontan procedure, the atrial septal defect is test occluded. Patients with mean right atrial and pulmonary artery pressures > 15 mm Hg are discharged with the atrial septal defect open. METHODS: Twelve patients (20 months to 12 years old) underwent evaluation and closure of the atrial septal defect at a mean interval of 3.8 months (range 1 to 18) after the Fontan procedure. Each patient underwent full right and left heart catheterization. Cardiac output was obtained using the cine-volume method. The study included six patients with a high transpulmonary gradient or poor ventricular function preoperatively, or both (high risk group) and six who had only borderline increased pulmonary vascular resistance (low risk group). Patients in both groups had a mean right atrial pressure > 15 mm Hg when the atrial defect was test occluded in the first week after the Fontan procedure. RESULTS: All results are given as mean value +/- SD. Ventricular end-diastolic pressure was significantly lower (p = 0.03) with the atrial septal defect open in low risk patients (6 +/- 3 mm Hg) than in high risk patients (10 +/- 3 mm Hg). With the atrial septal defect open, low risk patients had a significantly higher (p = 0.04) cardiac index (4.87 +/- 0.81 liters/min per m2) than the high risk patients (3.96 +/- 0.47 liters/min per m2). There was no significant difference (p = 0.14) in cardiac index between the two groups with occlusion of the atrial septal defect. Oxygen delivery was also significantly higher (p < 0.05) with the atrial septal defect open in low risk patients (836 +/- 99 ml/min per m2) than in high risk patients (704 +/- 106 ml/min per m2). There was no significant difference (p = 0.89) in oxygen delivery between the two groups with occlusion of the atrial septal defect. With the atrial septal defect open, the interatrial gradient was not significantly different in low risk patients (4 +/- 1 mm Hg) from that in high risk patients (4 +/- 1 mm Hg). CONCLUSIONS: These data show that an interatrial communication results in increased postoperative systemic perfusion and oxygen delivery in patients with good diastolic ventricular function after the Fontan procedure.

Atrial Function↗
PubMed2004

Ambulatory procedures for urinary incontinence in the United States, 1994-1996.

OBJECTIVE: The objective of our study was to describe the national rates of ambulatory surgery for urinary incontinence in women. STUDY DESIGN: We used the National Survey of Ambulatory Surgery, a federal database that samples outpatient surgery in the United States. Data from 1994 to 1996 were analyzed for diagnoses and procedures coded using the International Classification of Diseases, 9th revision, Clinical Modification, classification system. Age-adjusted rates were calculated with use of the 1990 census population and compared for change over time by using the score test for linear trend. RESULTS: The estimated number of women undergoing outpatient surgery for urinary incontinence increased from 7,200 in 1994 to 15,900 in 1996 (P=.3), whereas the age-adjusted rate remained stable at approximately 10 procedures per 100,000 women per year. The procedures performed included "other repair of the bladder" (ICD-9-CM code 57.89), "other repair of urinary stress incontinence" (code 59.7), plication of the urethrovesical junction, suprapubic sling operation, retropubic urethral suspension, paraurethral suspension, and levator muscle operation. The mean age of women undergoing these procedures was 58+/-14.5 years. Women undergoing incontinence procedures were 76% white, 0.3% African American, and 24% other (including unknown). Ninety-two percent of the procedures were completed at hospitals, whereas 8% were performed at free-standing ambulatory surgery centers. CONCLUSION: Between 1994 and 1996, the number of ambulatory surgeries for urinary incontinence in women doubled.

Adult↗
PubMed2006

A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures.

STUDY OBJECTIVE: We compare adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED). METHODS: Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children's hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg i.v. or 4 mg/kg i.m. Demographics, adverse events, sedation efficacy, and length of sedation were recorded. RESULTS: Two hundred twenty-five patients were randomized (116 i.v., 109 i.m.). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 i.v. and 99 i.m. Respiratory adverse events were similar between groups (i.v. 8.3% versus i.m. 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the i.m. group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9). Using the Faces Pain Scale, patients in the i.m. group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the i.m. group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 i.m. versus 0.74 i.v.; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the i.m. group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine i.m. CONCLUSION: In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg i.m. was more effective than 1 mg/kg i.v. but demonstrated significantly longer recovery times and more vomiting.

Adolescent↗
PubMed2005

The off-pump Fontan procedure by simply cross-clamping the inferior caval vein.

BACKGROUND: We previously used the Fontan procedure, when applicable, by placing a temporary bypass from the inferior vena cava to the atrium. Alternatively, we have striven to achieve the procedure even without use of a temporary bypass in patients having collaterals between the inferior vena cava and the superior vena cava, so as to simplify the procedure. The azygous vein was intentionally left patent at the bidirectional Glenn procedure in the most recent 9 patients, expecting reasonable venovenous communication at Fontan completion. Surgical results will be described for the preliminary experience. METHODS: Since 2001, this alternative technique has been attempted in 34 patients undergoing the staged Fontan procedure, and eventually used in 22. Duration between the staged procedures was 4 to 108 months (median, 10 months). We considered that the technique was feasible unless femoral venous pressure exceeded 20 mm Hg immediately after cross-clamping the inferior vena cava. Although catheterization before the Fontan completion illustrated development of venovenous collaterals in 14 patients, oxygen saturation remained greater than 80% throughout the period of the bidirectional Glenn physiology. RESULTS: In all 22 patients, the extracardiac channel was readily reconstructed with an excellent surgical field of view, without operative mortality. On cross-clamping the inferior vena cava, the systemic circulation could be well maintained by administration of dopamine. Oxygen saturation immediately became approximately 97% to 100%. Maximal pressure gradient was 11 +/- 5 mm Hg between the superior vena cava and the femoral vein. Postoperatively, serum concentration of enzymes did not critically increase (maximal aspartate transaminase, 96 +/- 89 U/L; alanine transaminase, 65 +/- 59 U/L; total bilirubin, 1.8 +/- 1.1 mg/dL; creatine kinase, 437 +/- 230 U/L). CONCLUSIONS: This alternative technique, when feasible under the current criteria, was simple and did not provide any clinically significant impediments.

Child↗
PubMed2005

Improved interstage mortality with the modified Norwood procedure: a meta-analysis.

BACKGROUND: Modification of the Norwood procedure has been reported to improve immediate postoperative mortality compared with the classic Norwood. Interstage mortality has not been shown to be improved with the modified Norwood probably because of the small number of patients from each institution. The goal of this study was to determine if meta-analysis would provide sufficient data to prove statistical difference in interstage mortality for the modified Norwood procedure. METHODS: PubMed was searched using six different terms individually for articles from January 2003 to October 2004. Manuscripts that compared the classic to modified Norwood were reviewed. Mantel-Haenszel analysis was used to evaluate the relationship between treatment method and mortality stratified across hospitals. The Breslow-Day procedure tested homogeneity of odds ratio across hospitals. Separate analyses were performed for inpatient and interstage periods. RESULTS: A total of 4,545 citations was screened. Five manuscripts met the criteria. Seventy-two patients undergoing classic Norwood and 84 patients undergoing modified Norwood survived to initial hospital discharge. The Breslow-Day statistic supported homogeneity of odds ratios for survival across hospitals (chi2 = 2.09, df = 4, p = 0.72). Odds of interstage death was 11.6 times greater (2.2 to 62.1, 95% CI) for the classic Norwood compared with the modified Norwood procedure. This difference was statistically significant by the Mantel-Haenszel chi2 (11.0, p = 0.001). The Breslow-Day statistic supported homogeneity of the odds ratios across hospitals (chi2 = 3.1, df = 4, p = 0.53). CONCLUSIONS: The modified Norwood procedure has a significantly lower interstage mortality compared with the classic Norwood procedure. A large randomized study is needed to determine whether these results remain consistent.

Cardiac Surgical Procedures↗
PubMed2005

Analysis of the Nuss procedure for pectus excavatum in different age groups.

BACKGROUND: The Nuss procedure is a newly developed operative method for minimally invasive repair of pectus excavatum in pediatric patients. However, the surgical indication for this procedure has been extended into adult patients. The aim of this study was to assess the surgical outcome of the Nuss procedure in different age groups and to analyze its feasibility in the adult population. METHODS: From December 1999 to March 2003, 51 patients (40 males and 11 females) with pectus excavatum underwent the Nuss procedure. We classified patients into three groups based on age (pediatric, adolescent, and adult), retrospectively analyzed demographic, intraoperative and postoperative data, and compared outcomes among each group. RESULTS: Mean operation time was 52.0 +/- 22.9 minutes, 80.4 +/- 27.4 minutes, and 127.3 +/- 44.9 minutes in the pediatric, adolescent, and adult groups, respectively (p < 0.001). Postoperative complications occurred in 3 of 27 patients (11.1%) in the pediatric group and in 7 of 12 patients (58.3%) in both the adolescent and adult groups (p = 0.002). Reoperations were performed due to complications in 1 of 27 patients (3.7%) in the pediatric group, 2 of 12 patients (16.6%) in the adolescent group, and 5 of 12 patients (41.7%) in the adult group (p = 0.001). CONCLUSIONS: The Nuss procedure is highly recommended in pediatric patients with pectus excavatum. However, in adults it is necessary to select patients carefully because of the longer operation time and higher incidence of complications associated with the procedure in this population.

Adolescent↗
PubMed2005

Right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig shunt in preparation to hemi-Fontan procedure in children with hypoplastic left heart syndrome.

OBJECTIVE: The advantageous effect of right ventricle-to-pulmonary artery shunt (RV-PA) on the early postoperative hemodynamics in the Norwood procedure for hypoplastic left heart syndrome (HLHS) is well known. Numerous controversies still exist with respect to the late consequences of this new palliation method in preparation for the second stage procedure. METHODS: Between September 1997 and September 2004, a consecutive series of 78 children with HLHS from a single institution underwent the hemi-Fontan procedure: Group 1 (n=27) after Blalock-Taussig shunt (BT), and Group 2 (n=51) after RV-PA. Hemodynamic, echocardiographic and clinical perioperative data were analyzed. RESULTS: There were no significant differences in the age and operative weight (Group 1: 6.9+/-1.04 months, 6.22+/-0.99 kg; Group 2: 6.57+/-1.12 months, 6.36+/-0.86 kg). Children after RV-PA were characterized by a significantly higher preoperative hematocrit value (P=0.014), lower aortic and superior vena cava oxygen blood saturation (P<0.001, P=0.024), severe right ventricle hypertrophy more rarely diagnosed in echocardiography (P<0.004), lower Qp:Qs ratio (P=0.011), larger right (P=0.001) and left (P=0.006) pulmonary artery index and a shorter intensive care unit stay after the hemi-Fontan procedure (P=0.004). CONCLUSIONS: The Norwood procedure with the RV-PA shunt provides satisfactory late hemodynamics and improves the development of the pulmonary arteries. Children with hypoplastic left heart syndrome subjected to this new method of palliation are good candidates for the hemi-Fontan procedure.

Anastomosis, Surgical↗
PubMed2004

Nitrous oxide-oxygen inhalation for outpatient otologic examination and minor procedures performed on the uncooperative child.

OBJECTIVE: Otomicroscopic examination with suctioning of ears or other procedures is frequently uncomfortable especially for children. Anxiety and pain with lack of cooperation may result in trauma to the ear, incompletion of the examination, delayed diagnosis and treatment and need for completion of the examination under general anesthesia. The purpose of this study was to evaluate the efficacy and safety of utilizing nitrous oxide-oxygen inhalation for sedation and analgesia in otologic examination and minor surgical procedures performed on the uncooperative child at the outpatient clinic. METHODS: In a prospective pilot case series study conducted at the Pediatric Otolaryngology outpatient clinic of a tertiary medical center, nitrous oxide-oxygen inhalation was administered by the examining otolaryngologist and the assisting nurse. The study group included children over 2 years old, for which an accurate diagnosis of ear pathology could not be made or a minor surgical procedure could not be tolerated because of anxiety and lack of cooperation. RESULTS: Completion of the indicated procedure was successful in 21 of 24 patients (88%). Full cooperation, where no restraint was necessary was achieved in 20 of 24 patients (83%). The mean rank pain scores, evaluated separately by the patient, parent and staff, were in the mild pain range using a 0-10 coding for Faces Pain Rating Scale. The mean procedure time was 8.9 min. An adverse reaction, vomiting, occurred in one patient. Twenty-one of 24 parents stated that they would repeat the procedure if necessary. CONCLUSION: This pilot study shows the potential usefulness of nitrous oxide-oxygen inhalation administered by an otolaryngologist in the outpatient clinic. Alleviation of pain and anxiety and avoiding the need for physical restraint is an important goal that can be achieved with this form of sedation.

Anesthetics, Inhalation↗
PubMed2004

Cardiac transplantation after the Fontan or Glenn procedure.

OBJECTIVES: The purpose of this study was to review the clinical course and outcome of cardiac transplantation after a failed Glenn or Fontan procedure. BACKGROUND: Late complications of the Glenn or Fontan procedure, including ventricular failure, cyanosis, protein-losing enteropathy, thromboembolism, and dysrhythmias often lead to significant morbidity and mortality. If other therapies are ineffective, cardiac transplantation is the only therapeutic recourse. Transplantation in this unique population presents significant challenges in the operative and perioperative periods. METHODS: The anatomic diagnoses, previous operations, clinical status, and indications for transplantation were characterized in patients transplanted after a Glenn or Fontan procedure. Outcomes after transplantation, including postoperative complications and mortality, were reviewed. Comparisons were made between survivors and nonsurvivors. RESULTS: Primary orthotopic cardiac transplantation was performed in 35 patients (mean age 15.7 +/- 8.5 years) with a mean follow-up of 54 +/- 46 months. A total of 11 patients had undergone a Glenn shunt and 24 patients a Fontan procedure. Indications for transplantation were a combination of causes including ventricular dysfunction, failed Fontan physiology, and/or cyanosis. Ten patients died <or=2 months after transplantation; nine of the deaths occurred in the Fontan patients. Overall, one-year survival was 71.5%, and five-year survival was 67.5%. Survival was not significantly different between patients transplanted after a Glenn or Fontan procedure and patients transplanted for other etiologies. CONCLUSIONS: Cardiac transplantation can be performed successfully in patients with end-stage congenital heart disease after a Glenn or Fontan procedure, with outcomes similar to transplantation for end-stage heart failure secondary to other etiologies.

Adolescent↗