Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants / Desfechos clínicos após tratamento mais conservador da persistência do canal arterial em prematuros

Abstract Objective: Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. Method: Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. Results: This study included 188 patients (27 ± 2 weeks, 973 ± 272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p < 0.001) and surgical closure (34.5% P1 versus 16.1% P2, p < 0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p = 0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p = 0.403), necrotizing enterocolitis (15.5% versus 6.9%, p = 0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p = 0.264), mortality (17.5% versus 15.2%, p = 0.690) or survival-without-morbidity adjusted OR = 1.10 (95% CI: 0.55-2.22); p = 0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n = 82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p = 0.019) and more survival-without-morbidity (20% versus 45.6%, p = 0.028) were found. Conclusion: A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated.

Resumo Objetivo O tratamento da persistência do canal arterial ainda é controverso. Nosso objetivo foi descrever o impacto de uma abordagem mais conservadora em nossas taxas de tratamento e nos principais desfechos da prematuridade, especialmente em prematuros com < 26 semanas de gestação. Método Revisão de prontuários de lactentes com ≤ 30 semanas e persistência do canal arterial entre 2009-2016 em dois centros. Em 2011, mudamos o manejo da persistência do canal arterial: no primeiro período (2009-2011), os pacientes que não apresentaram sucesso com o tratamento clínico foram submetidos a fechamento cirúrgico; no segundo período (2012-2016), apenas aqueles com comprometimento cardiopulmonar foram submetidos ao fechamento cirúrgico. Comparamos o tratamento clínico, fechamento cirúrgico, mortalidade e sobrevida sem morbidade. Resultados Foram incluídos 188 pacientes (27 ± 2 semanas, 973 ± 272 gramas); 63 em P1 e 125 em P2. Em P2, foram observadas taxas significativamente mais baixas de tratamento clínico (85,7% no P1 versus 56% no P2, p < 0,001) e fechamento cirúrgico (34,5% no P1 versus 16,1% no P2, p < 0,001). Não foram encontradas diferenças em relação à doença pulmonar crônica (28,8% versus 13,9%, p = 0,056), retinopatia grave da prematuridade (7,5% versus 11,8%, p = 0,403), enterocolite necrosante (15,5% versus 6,9%, p = 0,071), hemorragia intraventricular grave (25,4% versus 18,4%, p = 0,264), mortalidade (17,5% versus 15,2%, p = 0,690) ou OR ajustado pela sobrevida sem morbidade = 1,10 (IC95%: 0,55-2,22); p = 0,783. Em P2, 24,5% dos pacientes receberam alta com persistência do canal arterial. O subgrupo nascido entre 23 a 26 semanas (n = 82) apresentou diferenças significativas, foram encontradas menor incidência de doença pulmonar crônica (50% versus 19,6%, p = 0,019) e maior sobrevida sem morbidade (20% versus 45,6%, p = 0,028). Conclusão Uma abordagem conservadora em prematuros com persistência do canal arterial pode evitar tratamentos clínicos e cirúrgicos, sem um impacto significativo na sobrevida sem morbidade. No entanto, dois terços dos prematuros com menos de 26 semanas ainda são tratados.

Surgical closure of large splenorenal shunt may accelerate recovery from hepato-pulmonary syndrome in liver transplant patients / 世界急诊医学杂志（英文）

BACKGROUND@#Hepatopulmonary syndrome (HPS) is not uncommon in the setting of liver disease, especially in liver cirrhosis patients. The prevalence of HPS in liver cirrhosis patients varies from 4% to 47%.[1-3] About the definition of HPS, it is a pulmonary vascular disorder with evidence of intrapulmonary arterial venous shunt.[4] Pulmonary dyspnea and polycythemia are common presentations of HPS. Dyspnea, cyanosis and clubbed fingers were present in most of all cases. Spider nevi is another common clinical feature of patients with HPS.

Diagnosis And Treatment Of Esophagic Trauma In A Reference Hospital.

Background. Penetrating lesions of the esophagus are more common than blunt injuries. The bullet wound (75%) is the main cause of these. In traumatic injuries, primary surgical repair is the standard of treatment. Methods. Observational, Descriptive, cross-sectional, retrospective analysis of patients with esophageal trauma during January 2017 to December 2018. Results.There were 4 male patients, average of hospital stay 37.4 days. The mechanism of injury was: 2 due to injury with a puncturing instrument, 1 due to a gunshot wound (HPAF) and another injury due to perforation with a foreign body. Surgical treatment was: 3 of 4 patients underwent esophageal rafa and one of them had a trachea rafa with a sternocleidomastoid ap. The complications were esophageal stula and tracheal stula. Conclusions.These types of injuries are potentially fatal if there is a delay in diagnosis and treatment.

Application of TEE in minimal invasive surgical closure of atrial and ventricular septal defects / 中国介入影像与治疗学

Objective: To explore the value of TEE-guided surgical minimal invasive closure of atrial septal defects (ASD) and ventricular septal defects (VSD). Methods: Totally 58 patients with ASD and 129 patients with VSD underwent TEE-guided minimal invasive surgical closure. After small chest wall incision, under TEE monitoring, the accurate puncture point of right atrium or right ventricular wall was selected, then arterial hemostatic sheath passed through the gap. Multi-section TEE was used to confirm that the occluder position was suitable. Then the occluder was released when no significant residual shunt and valve complication was observed. Results: Minimal invasive surgical closure was successfully performed in all 58 ASD patients, with small residual shunts were found in 8 cases. Minimal invasive surgical closure of VSD was successfully performed in 114 patients but failed in 15 patients who then underwent open heart repair. Among 114 patients with successfully occluded VSD, 19 patients displayed minimal residual shunt, 2 patients displayed right ventricular outflow tract blood flow velocity increased, and the guide wire smoothly entered the gap in 1 patient after changing the right ventricular wall puncture point. Conclusion: TEE is useful for minimal invasive surgical closure of ASD and VSD, included measuring the size and position, choosing the occluder size, determing operative approach, guiding occluder released and evaluating instant therapeutic effect.

Características de los pacientes post operados de comunicación interventricular en el Departamento de Cardiología Pediátrica del Hospital de Clínicas / Characteristics of post-operated patients of interventricular communication in the Department of Pediatric Cardiology of the Hospital de Clinics

Introducción: la comunicación interventricular (CIV) es una cardiopatía congénita frecuente, que varía desde un defecto diminuto sin consecuencias hemodinámicas o un defecto grande, acompañado de insuficiencia cardiaca e hipertensión pulmonar. Aunque el tratamiento médico consigue controlar la insuficiencia cardiaca, es indudable que en algunos casos es necesario el cierre quirúrgico. Objetivo: describir las características clínicas del pre y post operatorio de los pacientes sometidos a cierre de CIV. Metodología: estudio observacional, descriptivo, retrospectivo, que incluyo a 74 pacientes de 3 meses a 16 años de edad, sometidos a cierre quirúrgico de CIV en el Departamento de Cardiología Pediátrica del Hospital de Clínicas FCM-UNA en el periodo 2012-2017. Se describen variables clínicas, electrocardiográficas y ecocardiográficas en el pre y post operatorio. Se excluyeron los casos de óbito intra-operatorio, casos con defectos cardiacos congénitos complejos asociados a CIV y con canal auriculoventricular. Resultados: la CIV más frecuentemente intervenida fue la de tipo perimembranosa (95%) y la mayoría con clase funcional pre operatoria grado I (52%). Los parámetros post operatorios (electrocardiograma y ecocardiografía) normalizaron en la mayoría de los pacientes, con disminución de la evidencia de sobrecarga de las cámaras cardiacas. Se presentaron complicaciones infecciosas (67%) y pulmonares (neumotórax y atelectasias). La mortalidad fue 1,3%. Conclusión: el cierre quirúrgico de la CIV tuvo significativa morbilidad, baja mortalidad y excelente recuperación funcional.

Introduction: ventricular septal defect (VSD) is a frequent congenital heart disease, which varies from a minute defect without hemodynamic consequences to a large defect, accompanied by heart failure and pulmonary hypertension. Although medical treatment manages to control heart failure, it is undoubted that in some cases surgical closure is necessary. Objective: to describe the clinical characteristics of the pre- and post-operative of patients undergoing IVC closure. Methodology: observational, descriptive, retrospective study, which included 74 patients from 3 months to 16 years of age, undergoing surgical closure of VSD in the Pediatric Cardiology Department of Hospital de Clínicas FCM-UNA in the 2012-2017 period. Clinical, electrocardiographic and echocardiographic variables are described in the pre- and postoperative period. Cases of intra-operative death, cases with complex congenital heart defects associated with VSD and atrioventricular canal were excluded. Results: the most frequently intervened VSD was the perimembranous type (95%) and the majority with preoperative grade I functional class (52%). Post-operative parameters (electrocardiogram and echocardiography) normalized in most patients, with a decrease in evidence of cardiac chamber overload. Infectious (67%) and pulmonary (pneumothorax and atelectasis) complications occurred. The mortality was 1.3%. Conclusion: Surgical closure of the VSD had significant morbidity, low mortality and excellent functional recovery.

Estudio comparativo de cierre de cuero cabelludo en neurocirugías supratentoriales: intradérmica vs. surget / Comparative study of scalp closure in supratentorial neurosurgery: intradermal vs. surget

Introducción: El cierre de cuero cabelludo en neurocirugías supratentoriales mediante sutura intradérmica es una técnica poco difundida en la actualidad. En contraste, es común que se efectúen suturas de alta tensión con el fin de evitar dehiscencias, fístula de líquido cefalorraquídeo (LCR) y sangrado durante el período posquirúrgico, pero que no tienen buen resultado estético. Objetivo: Comparar las complicaciones relacionadas al cierre de cuero cabelludo que se presentaron en neurocirugías supratentoriales en un período de 19 meses, para determinar si utilizar un cierre de menor tensión y con mejor resultado estético, es igual de seguro que las técnicas de cierre habituales. Materiales y Métodos: Se incluyeron 84 casos de neurocirugías supratentoriales electivas. En 43 casos (control) se realizó el cierre mediante sutura continua tipo surget y en 41 casos (experimental) el cierre fue mediante sutura intradérmica. Resultados: Se presentaron 2 casos de infecciones, 1 en cada grupo (p= 0,97) y 1 caso de sangrado en el grupo control (p= 0,32). No se presentaron dehiscencias ni casos de fístula de LCR. Conclusiones: El cierre de cuero cabelludo mediante sutura intradérmica fue un método seguro que no generó una mayor incidencia de complicaciones y logró un mejor resultado estético a corto y largo plazo.

Background: Scalp closure by means of intradermal suture in patients who underwent supratentorial neurosurgeries is currently an uncommon technique. In contrast, it is usual to perform high tension sutures to avoid skin dehiscence, cerebrospinal fluid leak (CSF) and postoperative bleeding; however it usually results in unsatisfactory aesthetic results. Aim: Comparing complications, over a two year period, related to scalp closure occurred in supratentorial neurosurgeries. The goal is to establish if the intradermal suture is as safe as the current high tension closure technique.Materials and Methods: Eighty-four patients were included. In forty-three cases (control) continuous high tension suture (surget) was performed. The other forty-one cases (experimental) underwent intradermal suture. Results: Two infection cases occurred, one from each group (p= 0, 97). There was one case of bleeding that took place in the control group (p= 0,32). Neither dehiscence nor CSF leak occurred in any of the trial cases.Conclusions: Intradermal suture performed for scalp closure was as safe as surget in terms of complications occurrence and obtained better cosmetic results in the short and long term.

Cierre de comunicación interventricular en menores de un año en un hospital público / Ventricular septal defect repair in children during first year of life in a public hospital

Introducción. La comunicación interventricular (CIV) es la cardiopatía congénita más frecuente y el cierre quirúrgico primario es la estrategia de elección para corregirla. El objetivo es describir los resultados de la reparación quirúrgica en menores de 1 año y analizar factores de riesgo de morbilidad y mortalidad. Pacientes y métodos. Estudio retrospectivo; se incluyeron todos los pacientes con CIV operados entre 2004 y 2011. Se registraron variables demográficas, de la cirugía y del posoperatorio: edad, peso, síndrome genético, tipo de CIV, días de internación, complicaciones y evolución. Como factores de riesgo de mortalidad y morbilidad, se analizaron edad < 6 m, peso < 3 kg, síndrome de Down, desnutrición e infección respiratoria previa. Resultados. Se operaron 256 pacientes, con edad de 5,3 meses (21 d-1 a), peso de 4,75 kg (2,2-13), 32% con síndrome de Down y 17,5% con ventilación mecánica preoperatoria. La CIV tipo perimembranosa fue la más frecuente (62%). El 28% presentó alguna complicación y el 7% requirió reoperación por sangrado, infección o defecto. La mediana de internación fue de 6 días (1-185). Se registró una mortalidad posoperatoria de 3%. La desnutrición, edad < 6 m, peso < 3 kg y la infección respiratoria previa se asociaron a una internación prolongada. No se identificaron factores de riesgo para la mortalidad. Conclusión. En nuestra institución, el cierre quirúrgico primario de la CIV es un procedimiento con resultados satisfactorios.

Objective. Ventricular septal defect (VSD) is the most common congenital heart disease; primary surgical closure is the usual strategy for repairing it. Our objective is to describe results of surgical repair in children under 1 year of age and analyze risk factors for morbidity and mortality. Patients and Methods. Retrospective study; all patients with VSD repaired between 2004 and 2011 were included. Demographic, surgical procedure and postoperative variables were recorded: age, weight, genetic syndrome, type of VSD, length of stay, complications and outcome. Risk factors of mortality and morbidity: age < 6 m, weight < 3 kg, Down, malnutrition and respiratory infection prior syndrome were analyzed. Results. 256 patients, age 5.3 months (21d-1y), weight 4.75 kg (2.2 to 13), 32% with Down syndrome and 17.5% with preoperative mechanical ventilation were operated. Perimembranous VSD was the most frequent type (62%). 28% experienced complications and 7% required reoperation for bleeding, infection or defect. The median hospital stay was 6 days (1-185). Postoperative 30 days mortality was 3%. Age < 6 m, weight < 3 kg, malnutrition and prior respiratory viral infection were associated with prolonged hospitalization, but no risk factors for mortality were identified. Conclusion. The primary surgical closure of the VSD is a procedure with satisfactory results at our institution.

A survey of the indications for early closure of ostium secundum atrial septal defects and subsequent progress of children in whom this has been undertaken.

Objectives: Closure of isolated secundum atrial septal defect (ASD) is generally recommended at the age of 4 to 5 years. However, there are children with isolated secundum ASDs in whom early closure is performed. The aim of this study is to describe the conditions that led to the decision for early closure and to determine whether these conditions were resolved by means of closure of the defect. Methods: The records of 16 patients who underwent surgical closure of isolated ASD before 24 month of life from 2001 to 2010 at Southampton University Hospital were scrutinised to collect data. Results: There were eight patients with recurrent respiratory tract infections and failure to thrive, three with only recurrent respiratory tract infection, two with evidence of high pulmonary pressures and one with heart failure. Two patients were asymptomatic but had large defects with significant right sided volume overloading. All patients survived surgery and most of them had an uneventful postoperative period. All patients showed clear improvement of their symptoms during the follow up period. Two patients continued to fail to thrive despite closure of ASD but both had other problems to account for the failure to thrive. Conclusion: All symptomatic patients with ostium secundum ASD improved following closure of the ASD before two years of age. Co-existing chromosomal or non cardiac anomalies can be associated with a continued tendency to a poor weight gain after ASD closure.

Anesthetic Management of Early Ligation of Patent Ductus Arteriosus for Premature Infants in the Neonatal Intensive Care Unit / 대한마취과학회지

BACKGROUND: Left-to-right shunt through patent ductus arteriosus (PDA) produces significant hemodynamic and respiratory derangements in premature infants. Combined diseases in these patients often preclude attempts to close the PDA medically with indomethacin. Recently, the efficacy of early surgical closure performed in neonatal intensive care unit (NICU) rather than in operating room (OR) has been emphasized to reduce the risks of transferring unstable infants. Therefore, we reviewed the anesthetic management and clinical status of premature infants who underwent early surgical closure of PDA in NICU. METHODS: Between 2001 and 2007, we reviewed retrospectively 17 premature infants with extremely low birth weight below 1,500 g and 33 weeks gestational age who underwent early ligation of PDA in NICU with left axillary minithoracotomy. RESULTS: The mean gestational age and weight of infants were 29.4 +/- 1.8 (26(+3) - 32) weeks and 849 +/- 165 (450 - 1,080) g. Most of the infants had complications related to PDA and prematurity. Diastolic blood pressure and pulse oxymetry saturation changed with ligation of PDA from 27.4 +/- 5.3 mmHg and 96.3 +/- 2.9% to 38.1 +/- 10.0 mmHg and 93.8 +/- 2.6%, respectively. The body temperature didn't show significant alterations. There was no direct procedure-related death although threeinfants died from pneumonia and sepsis at 29, 30 and 34 days postoperatively. CONCLUSIONS: Performing early PDA ligation in NICU was demonstrated to be safe and effective, especially in terms of providing continuous care and avoiding the risk of hypothermia.

Comparison between transcatheter and surgical closure of secundum atrial septal defect in patients over 40 years old / 介入放射学杂志

Objective To compare the safety and efficacy of transcatheter closure of secundum atrial septal defect(ASD)with surgical closure in patients over 40 years old.Methods A single center, nonrandomized concurrent study was performed in 233 consecutive adults from January,2004 to December, 2005.The patients were assigned to either the device or surgical closure group according to the patients' options.Technical success rate,complications,residual shunt,hospital stay,amount of blood transfusion and cost were compared .Results A total of 137 patients were in the group undergoing device closure,whereas 96 patients were in the surgical group.There was no differences in age,sex distribution or baseline cardiac function between the two groups.The sizes of the ASD were(18.9?5.4)mm for the device group and(24.9?6.8)mm for the surgical group(P＜0.001).The technical success rates were 97.1% for the device group and 100% for the surgical group(P=0.151).The residual shunt rates were 0.7% for the device group and 0% for the surgical group(P=0.583).Mortality was zero for both groups.The complication rates were 16.1% for the device group and 30.2% for the surgical group(P=0.015).The blood transfusion amounts were(273.1?491.5)ml for the surgical group and 0 ml for the device group(P＜0.001).The lengths of hospital stay were (4.6?3.3)days for the device group and(12.0?4.0)days for the surgical group(P＜0.001).The costs of hospital stay were 39 570.0?5 929.5 RMB for the device group and 29 839.6?7 533.1 RMB for the surgical group(P＜0.001).Conclusions The technical success rates for surgical versus device closure of ASD were not significantly different,however,the complication rate was lower and the length of hospital stay was shorter for device closure than those for surgical repair.Transcatheter closure of seeundum ASD is a safe and effective alternative to surgical repair in selected patients.(J Intervent Radiol,2007,16:79-83)