Review and discussion of the complications of minimally invasive pectus excavatum repair.

PURPOSE: To review and discuss the complications of minimally invasive pectus excavatum repair. METHODS: 329 patients underwent minimally invasive pectus repair between January 1987 and August 2000, including 14 patients who recurred after previous Ravitch repairs, 10 failed Nuss repairs (eight done elsewhere) and two failed Leonard repairs. All patients received antibiotics and vigorous incentive spirometry to prevent atelectasis, pneumonia and bar infection. Epidural anesthesia was used for postoperative analgesia to keep patients comfortable and stable postoperatively and to prevent bar displacement. Thoracoscopy was used during bar insertion to minimize the risk of mediastinal injury and to select the best position for the bar. A new introducer was developed to elevate the sternum before bar insertion. A stabilizing bar was created to minimize bar displacement. The duration of sternal bracing has been increased from two years to three or four years in selected patients. COMPLICATIONS: There were no deaths, no cardiac perforations and no cases of thoracic chondrodystrophy. Pneumothorax with spontaneous resolution occurred in 52 % of the patients, with 1.2 % requiring simple aspiration and 1.5 % requiring chest tube drainage. This complication has essentially been eliminated by using a "water seal system". Pericarditis occurred in 2.4 % with good response to Indomethacin in six out of eight patients and two patients also required pericardial fluid aspiration. Pneumonia occurred in 0.9 %. Wound infection occurred in 2.6 % resulting in bar infection in three out of the seven patients. Long-term antibiotics were successful in curing the infection in one patient, whereas the other two required bar removal at 12 and 18 months, respectively. Bar displacement occurred in 8.8 % of patients. However, the introduction of stabilizers decreased the incidence from 15.7 % before the use of stabilizers to 5.4 % with stabilizers. Wiring the bar and stabilizer together has decreased the incidence even further. RESULTS: Long-term outcome after bar removal showed an excellent result in 71 %, good result in 21 % and recurrence in 7.8 %. CONCLUSION: The minimally invasive technique has a low complication rate with excellent long-term results.

The effects of a pediatric unilateral inguinal hernia clinical pathway on quality and cost.

BACKGROUND/PURPOSE: The purpose of this study is to discover whether a pediatric inguinal hernia surgical clinical pathway (CP) reduces the frequency of wound infections, return visits, times associated with surgical repair, or costs. METHODS: A multidisciplinary team developed the inguinal hernia surgical clinical pathway. Healthy children greater than 50 weeks gestational age who required unilateral hernia repair were considered for the study. Two groups were formed: (1) an intervention group selected randomly (n = 46, CI = 95%, power = .80) from patients enrolled from November 1996 through April 1997, and (2) a retrospective cohort control group (n = 46) matched to each intervention patient by age, gender, and medical history. Analysis of variance and chi2 testing were used to test for significant differences between the 2 groups in postoperative wound infections, readmission and emergency department return visits within 72 hours, times associated with surgical repair, and costs. RESULTS: There were no significant differences in postoperative wound infections, times associated with surgical repair, or readmission rates within 72 hours. Total cost significantly decreased, by 10% (P< or = .05), for pathway patients ($982 v $880). CONCLUSION: These results show that the use of a pediatric inguinal hernia surgical clinical pathway is associated with reduced cost while maintaining quality of care.

A 10-year review of a minimally invasive technique for the correction of pectus excavatum.

PURPOSE: The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum. METHODS: From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure. RESULTS: Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon. CONCLUSIONS: This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

Superior mesenteric artery Doppler velocimetry and ultrasonographic assessment of fetal bowel in gastroschisis: a prospective longitudinal study.

OBJECTIVE: Our purpose was to determine whether Doppler velocimetry of the superior mesenteric artery and its mesenteric branches and ultrasonographic assessment of bowel can predict postnatal outcome in fetuses with gastroschisis. STUDY DESIGN: The normal reference range for the superior mesenteric artery pulsatility index was determined by studying 161 normal fetuses. Over a 24-month period superior mesenteric artery pulsatility index, superior mesenteric artery mesenteric branches systolic/diastolic ratio, bowel diameter, and bowel wall thickness were prospectively and longitudinally obtained from 17 fetuses with gastroschisis. Poor neonatal outcome was defined by bowel resection or staged repair of the defect or a hospital stay > 50 days. RESULTS: Doppler velocimetry of the superior mesenteric artery and its mesenteric branches proved minimally useful in prognosticating neonatal outcome. No difference was found in the superior mesenteric artery pulsatility index between the good and poor neonatal outcome groups (p = 0.99). Longitudinal data analysis on all fetuses with gastroschisis showed an increase in bowel diameter with advancing gestation (p < 0.0001). A greater rate of increase in bowel diameter with advancing gestation was noted in the poor-neonatal-outcome group compared with the good-neonatal-outcome group (p < 0.01). Mean bowel diameter obtained before delivery was significantly greater in the poor-neonatal-outcome group (p = 0.03). Bowel diameter obtained at 28 to 32 weeks was the best predictor of poor neonatal outcome. A cutoff value of bowel diameter > 10 mm at 28 to 32 weeks had a sensitivity of 83%, a specificity of 88%, a positive predictive value of 83%, and a negative predictive value of 88% for poor neonatal outcome. CONCLUSIONS: Doppler velocimetry of the superior mesenteric artery and its branches is not predictive of poor neonatal outcome in fetuses with gastroschisis. A bowel diameter > 10 mm between 28 and 32 weeks appears to be the best predictor of poor neonatal outcome. This newly defined variable warrants further investigation given its significant predictive power.

Transabdominal manually assisted reduction of pediatric intussusception: reappraisal of this historical technique.

PURPOSE: To determine whether manual manipulation of the abdomen during intussusception reduction improves the success rate or affects morbidity. MATERIALS AND METHODS: A retrospective study was performed in 38 cases of intussusception in 35 children over a 33-month period at a pediatric hospital. In all cases, pneumostatic pressure was used as the initial method of treatment. A comparative review of the intussusception literature was also performed. RESULTS: Reduction was achieved with pneumostatic pressure alone in 22 cases (an initial success rate of 58%). Transabdominal manual manipulation was used in 10 cases after initial pneumostatic reduction failed; seven of these 10 cases were treated successfully. These seven additional successes, attributed to manual assistance, significantly improved the success rate from 58% to 76% (P < .016). No perforation or other complication occurred. CONCLUSION: These results and findings of the literature review indicate that transabdominal manual assistance during reduction is a potentially useful technique that has been shunned without scientific basis for longer than 40 years.

Sequential sac ligation for giant omphalocele.

The authors describe a technique for the management of giant omphalocele in which the sac is not resected, but used to sequentially reduce the contents into the abdominal cavity. Three patients were treated in this fashion. Delayed primary fascial closure was achieved in two. The third patient did not have complete reduction after 3 weeks, and temporary placement of a silastic sheet was required. The sac remained intact in all three cases, and neither infection nor injury to the abdominal contents occurred. This technique has the advantages of maintaining an intact membrane and avoiding the initial operative placement of a prosthetic silo in these sometimes critically ill neonates.

Congenital urethral fistula with normal anus: a report of two cases.

Congenital rectourethral or anourethral fistulae without imperforate anus in males are rare, representing less than 1% of anorectal malformations. We report our experience with two males with "N type" urethral fistulae. One, a 5-year-old boy, presented with recurrent urinary tract infections (UTIs) and passage of urine per anus. Investigations included a voiding cystourethrogram (VCUG), which demonstrated a fistula from the urethra to the anus. On physical examination, a small perianal opening was noted just outside the anus, which drained a small amount of urine after voiding. The fistula was excised via a perineal approach. The second patient is a 5-year-old boy with a long history of recurrent UTI requiring multiple hospitalizations since the newborn period. Chronic renal failure developed as a complication of repeated urinary tract infections. Investigations showed a single hydronephrotic pelvic kidney and a small bladder. He underwent numerous diagnostic and reconstructive procedures including cystoscopy and augmentation cystoplasty. Recurrent infections continued and an N type anourethral fistula was eventually diagnosed. The fistula was located between the anal canal and the membranous urethra. An anterior perineal approach was also used. Both fistulae were easily located, and reconstructive surgery of the urethra was not required. Postoperative VCUGs in both patients were normal. They have been free of infection with normal urinary continence since resection of the fistula. Congenital N type anourethral fistulae are rare, but should be considered in cases of recurrent urinary tract infections. The diagnosis may be missed by endoscopic procedures, but VCUG should demonstrate the fistulous tract.

Cystic neuroblastoma.

In the newborn, cystic masses of the adrenal gland are unusual findings and most are secondary to hemorrhage. We present a patient with a clinical history typical for adrenal hemorrhage who was found to have a thick walled cystic adrenal mass on both physical and ultrasound examination. During evaluation the mass decreased in size, but vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels were elevated. Laparotomy and left adrenalectomy confirmed the diagnosis of a cystic neuroblastoma. Adrenal cyst, adrenal abscess, and cystic neuroblastoma are all rare entities in the newborn. We recommend that all cystic masses of the adrenal be evaluated by urinary VMA and HVA and that the possibility of cystic neuroblastoma be kept in mind when an adrenal cystic mass is followed nonoperatively.

Management of complex ovarian cysts presenting in the first year of life.

With more frequent antenatal and postnatal diagnosis, the management of ovarian cysts has become somewhat controversial. Management protocols for simple ovarian cysts have been proposed. The purpose of this study was to establish a management protocol for complex ovarian cysts presenting antenatally and in the first year of life. We reviewed the records of nine infants who underwent surgical treatment for ovarian cysts over a 10-year period (1980 through 1989). Antenatal ultrasound performed between 24 and 34 weeks of gestation showed ovarian cysts in six infants. All six infants had complex cysts ranging in size from 3 to 10 cm on postnatal ultrasound. Exploration with oophorectomy or salpingooophorectomy was carried out at 2 days to 3 months of age for ovarian torsion. Ovarian cysts measuring up to 7 cm were diagnosed postnatally in three infants from 1 day to 7 months of age with ultrasound confirmation of complex, cystic intraabdominal masses. All patients underwent salpingooophorectomy, two for tuboovarian torsion and the third patient for a juvenile granulosa cell tumor. We recommend that all complex ovarian cysts, regardless of size, be surgically removed because they represent torsion, neoplasm, or alternate diagnoses, and removal can prevent possible complications.

Distal congenital esophageal stenosis associated with esophageal atresia.

A series of six patients with congenital esophageal stenosis associated with esophageal atresia (EA) and distal tracheoesophageal fistula is presented. Three patients required only repeated dilatations, and have had good results. Two patients required limited resections of the distal esophagus, with excellent results. One patient died following a Heller myotomy. Tracheobronchial rests were present in the distal esophagus in the latter three patients. Diagnosis of congenital distal esophageal stenosis following repair of EA requires a high index of suspicion and a careful review of previous esophagrams. It is important to exclude anastomotic stricture and stenosis associated with gastroesophageal reflux. This requires barium esophagram, esophagoscopy with biopsy, and esophageal pH monitoring. Once a congenital basis for distal esophageal stenosis is suspected, management consists of dilatation by bouginage followed by balloon dilatation. Resection is reserved for persistent stenoses from tracheobronchial rests, which usually do not respond to dilatations.