Mechanical injuries to the ipsilateral non-diseased lobes(s) during pulmonary resection--another factor causing postoperative complications.

BACKGROUND: The occurrence of complications after major pulmonary resection is known to be related to various factors. However, peri-surgical injuries to the ipsilateral non-diseased lobes(s) occurring during resection have never been mentioned in the literature. This study aimed to verify the injury in cases after lobectomy and wedge resection. METHODS: Data from eighteen patients who underwent lobectomy or wedge resection for malignant tumor between January 2003 and January 2004 were collected. All patients had pre- and postoperative examinations of alveolar-capillary membrane (A/C) permeability using 99m TC-DPTA radioaerosol. RESULTS: Ten lobectomies and eight wedge resection were performed. Using the paired t-test with each patient's pre-operative A/C permeability as his own control data, the postoperative A/C permeability of the ipsilateral non-diseased lobe(s) was found to be significantly increased. The degree of increase in the lobectomy group was the same as that in the wedge resection group. However, no significant change was found on the contralateral side in both groups. CONCLUSION: The degree of increase of permeability was the same in both groups, indicating that the effects of stretch on the surviving lung are not a contributing factor to the change in A/C permeability. The mechanical injuries during the pulmonary surgical procedure alter the permeability, which could be a possible factor causing postoperative pulmonary complications.

Tumour lysis syndrome developing during an operation.

We describe an unusual case of tumour lysis syndrome in a child with a high-grade lymphoma undergoing a staging laparotomy. The patient presented with a refractory ventricular arrhythmia, which required continuous resuscitation in the operating room and continuous venous-venous haemodialysis in the intensive care unit. This case report suggests that surgery is a possible trigger for developing tumour lysis syndrome, so anaesthetists should be alert to this possibility during surgery in patients with pre-existing high tumour burdens.

Video-assisted thoracic surgery is minimally invasive, but is it less traumatic?

BACKGROUND: Video-assisted thoracic surgery (VATS) is a minimally invasive procedure. This study aimed to evaluate whether the procedure is less traumatic to the ipsilateral non-diseased lobe(s) than open thoracotomy (OT) during pulmonary resection by a comparison of alveolar-capillary membrane (A/C) permeability. METHODS: Wedge resections were performed in twenty-seven patients with various types of primary and secondary malignant, solitary, pulmonary nodules. Fifteen patients had OT, while 12 patients had VATS. (99 m)Tc-DTPA radioaerosol studies were performed on the day before surgery and on the third or fourth day postoperatively. The images of the ipsilateral non-diseased lobe(s) were compared. RESULTS: Postoperatively, all patients had significantly increased A/C permeability at the ipsilateral non-diseased lobe(s). However, the degree of increase in the VATS group was the same as that of the OT group. Postoperative A/C permeability of the contralateral lung was not significantly different. CONCLUSIONS: Both procedures caused injury to the ipsilateral non-diseased lobe(s) in terms of A/C permeability at the same degree. Although VATS has been considered as a minimally invasive procedure, the trauma caused by VATS to the "disease-free lung" is the same as that caused by open thoracotomy.

Thoracoscopic decortication: first-line therapy for pediatric empyema.

Video-assisted thoracoscopic surgery (VATS) has become a popular and well-refined procedure. It has several advantages over open thoracotomy in terms of invasiveness and cosmetics. The aim of this study is to consider if VATS can serve as primary management for pediatric empyema. Between October 2000 and December 2002, 13 children with empyema receiving VATS were retrospectively reviewed. Of them, 5 had tube thoracostomy before VATS intervention (group T), and 8 had VATS as the initial treatment (group V). Their mean (+/- SD) age of groups V and T were 5.75 +/- 4.43 and 4.0 +/- 1.58 years, respectively. The children of group V had a shorter length of hospital stay (group V 10.7 +/- 3.54 days; group T 28.2 +/- 8.32 days), a shorter period of chest tube drainage (group V 5 +/- 1.87 days; group T 25 +/- 11.08 days), less transfusion (group V 0.4 +/- 0.17 units; group T 0.9 +/- 0.27 units) and less radiation exposure (group V 10.3 +/- 3.49; group T 23.4 +/- 11.64). No mortality was noted in the entire series. We conclude that primary VATS is a safe, effective and definitive method which can serve as first-line therapy for children with empyema.

Correlation of pulmonary 99mTc-DTPA ventilation and 99mTc-MAA perfusion scans with pulmonary function tests in asymptomatic asthmatic children.

Our objective was to examine and correlate 99mTc-diethylenetriaminopentaacetic acid (99mTc-DTPA) ventilation and 99mTc-macroaggregated albumin (99mTc-MAA) perfusion (V/Q) lung scans with spirometry in asymptomatic asthmatic children. We evaluated 89 subjects (age range, 6-15 years; mean age, 9.4 years), all with at least 70% predicted forced expiratory volume in 1 s (FEV(1)). There were four V/Q scan patterns: normal in 38 (42.7%), inhomogeneous ventilation in 11 (12.4%), matched defects in 25 (28.3%) and mismatched perfusion defects in 13 (14.6%). The maximal mid-expiratory flow rate (MMEF) of the normal scan group was significantly different from that in the other groups. The MMEF of the inhomogeneous group was significantly different from that in the matched defect group and the mismatched perfusion defect group. No other significant differences in spirometric indices were found. In two children with perfusion defects, pulmonary arteriograms demonstrated no obstructive lesions. In conclusion, lung scans provide diagnostic information in asymptomatic asthmatic children, even when they are uncooperative. Abnormal scans are common in these children and are significantly correlated with reduced MMEF (% predicted), reflecting small airway flow obstruction. The pathophysiology of V/Q defects in asymptomatic asthmatic children warrants further investigation.

Cyanosis caused by a huge obstructive right ventricular fibroma.

Cardiac fibromas are rare lesions which occur more often in infants and children than in adults. These tumors are benign proliferations of connective tissue most often found in the left ventricular myocardium or septum. In an 8-month-old infant with cyanosis and progressive exertional dyspnea, a huge cardiac tumor obstructing the right ventricular outflow tract (RVOT) was diagnosed by means of 2-dimensional echocardiography and cardiac catheterization. At surgery, a whitish gray solitary tumor measuring 5.0 x 4.5 cm could be well visualized. It was nearly totally resected, and the RVOT was reconstructed with an Equine pericardial patch. Histologic examination classified the tumor as a fibroma. Although surgical mortality in cardiac fibroma with RVOT obstruction is extremely high, early diagnosis and prompt excision of the tumor is mandatory in relieving its dangerous symptoms.

Simultaneous multiple viral infections in childhood acute lower respiratory tract infections in southern Taiwan.

Thirty paediatric patients with acute lower respiratory tract infections (ALRI) caused by simultaneous multiple viral infections (SMV) in a 3-year interval were reviewed. Twenty patients were infected with two viruses simultaneously; nine patients with three viruses; and one patient with four viruses. The frequency of individual viruses were: adenovirus, 18 (60 per cent); respiratory syncytial virus, 7 (23 per cent); influenza virus type A, 6 (20 per cent); influenza virus type B, 15 (50 per cent); parainfluenza virus type 1, 11 (37 per cent); parainfluenza virus type 3, 13 (43 per cent). There was no difference between the clinical presentations of ALRI with SMV and those of ALRI with a single virus. In conclusion, SMV was not uncommon in children with ALRI; the clinical presentations of multiple viral infection were similar to those of single viral infection.

Relationship between left atrial pressure and atrial natriuretic peptide in children with cardiac disease.

To evaluate the relationship between atrial pressure and the concentrations of atrial natriuretic peptide (ANP) in plasma of children with cardiac disease combined with increased left atrial loading. We extracted plasma ANP through a Sep-Pak C18 cartridge and proceeded to radioimmunoassay. Of the nine children, aged from 20 days to 10 years, cardiac diseases included transposition of the great arteries (four cases), ventricular septal defect (three cases), patent ductus arteriosus (one case) and mitral regurgitation (one case). The concentrations of ANP in plasma in the left atrium were greater than in the inferior vena cava, and the concentrations of ANP in plasma in the inferior vena cava correlated significantly with the mean left atrial pressure (r = 0.89, p < 0.01), and the concentrations of ANP in plasma in the left atrium correlated significantly with the mean left atrial pressure (r = 0.85, p < 0.01). This study indicated that left atrial pressure may have an important influence on secretion of ANP in various cardiac conditions.

Relationship between hemodynamics and plasma atrial natriuretic peptide in children with ventricular septal defect or patent ductus arteriosus.

To evaluate the relationship between concentrations of ANP in plasma of the right-sided central circulation and hemodynamic parameters in congenital heart disease with left-to-right shunt. We enrolled 20 children aged from 1 month to 4.8 years with ventricular septal defect (VSD) or patent ductus arteriosus (PDA). The concentrations of ANP in plasma were extracted through a cartridge (Sep-Pak C18) before being measured by radioimmunoassay. Significant increased concentrations of ANP in plasma from inferior vena cava (117.6 +/- 18.1 pg/mL), right atrium (160.6 +/- 21.6 pg/mL) to pulmonary artery (PA) (253.4 +/- 38.8 pg/mL) were recognized. In VSD (n = 10) and PDA (n = 10), the concentrations of ANP in plasma from the inferior vena cava correlated significantly with the ratio of pulmonary to systemic blood flow (Qp/Qs) (r = 0.69, p < 0.05; r = 0.94, p < 0.01 respectively), the systolic pulmonary artery pressure (r = 0.90, p < 0.01; r = 0.93, p < 0.01 respectively), the diastolic pulmonary artery pressure (r = 0.76, p < 0.02; r = 0.68, p < 0.05 respectively), and the mean pulmonary artery pressure (r = 0.88, p < 0.01; r = 0.87, p < 0.01 respectively). The concentrations of ANP in plasma from the pulmonary artery also correlated significantly with the Qp/Qs (r = 0.81, p < 0.01; r = 0.87, p < 0.01 respectively). The results indicated that left atrial volume loading may have an important influence on secretion of ANP in some congenital heart disease with left to right shunt.

[Somatomedin-C in infantile nutritional assessment with comparison with prealbumin, insulin and growth hormone].

Somatomedin-C (Sm-C) is also called insulin like growth factor I (IGF-I). It has insulin-like biological effects and serves as an anabolism-related mediator of growth hormone. Most Sm-C is synthesized in liver cells. There are decreased blood levels of Sm-C, prealbumin and insulin, but increased blood levels of growth hormone in the adult with malnutrition. We simultaneously measured the blood levels of the above four peptides in infants aged one month to one year. They were divided into four groups: normal, first class malnutrition, second class malnutrition and third class malnutrition. They were classified according to the Value of Nutrition Index. The utility of Sm-C measurement was compared to that of the measurements of prealbumin, insulin and growth hormone in the nutritional assessment. The results revealed that the blood level of Sm-C decreased more in the cases of severe malnutrition (Normal group: male 361.2 +/- 158.9 mU/ml (n = 18), female 499.3 +/- 227.8 mU/ml; (n = 19); First class malnutrition group: 256.9 +/- 81.1 mUU/ml (n = 17); Second class malnutrition group: 169.5 +/- 43.5 mU/ml (n = 15); And third class malnutrition group: 76.2 +/- 26.5 mU/ml (n = 18)). The blood level of prealbumin decreased more in the cases of severe malnutrition (Normal group: 17.8 +/- 2.1 mg/dl (n = 37); First class malnutrition: 11.8 +/- 3.5 mg/dl (n = 17); Second class malnutrition: 11.8 +/- 3.5 mg/dl (n = 15); And third class malnutrition: 9.7 +/- 2.4 mg/dl (n = 18)).(ABSTRACT TRUNCATED AT 250 WORDS)

Study on the children of Kaohsiung with acute viral infection of lower respiratory tract by direct immunofluorescence assay.

This study retrospectively reviewed those pediatric patients of acute lower respiratory tract infection with positive virus identification by direct immunofluorescence assay (Direct IF) from Jan, 1992 to Dec, 1993. One hundred and eighteen patients with 133 positive Direct IF results (107 cases with single virus identified, and 11 cases with more than one) were included. The sex ratio was 1.6:1 with males predominant; age, 22.1 (1 approximately 154.8) (months); duration of admission, 5.7 (1 approximately 69) (days); peripheral white blood cell count, 10,600 +/- 3,800/mm3; C-reactive protein, 17.0 (0 approximately 163.3) mu/ml; body temperature, 37.1 +/- 1.1 degrees C in those cases with single virus. The symptoms were cough 105 cases (98.1%), rhinorrhea 46 cases (43.0%), dyspnea and/or tachypnea 43 cases (40.2%) and diarrhea 15 cases (14.0%). The viruses identified were: Adenovirus (52 cases, 39.1%). Influenza B (45 cases, 33.8%), Parainfluenza 1 (28 cases, 20.1%), Parainfluenza 3 (19 cases 14.3%), Respiratory Syncytial virus (17 cases, 12.8%), and Influenza A (9 cases, 6.8%). The seasonal incidence rates were spring (49 cases, 36.8%), summer (46 cases, 34.6%), autumn (23 cases, 17.3%), and winter (15 cases, 11.3%). The results showed much similarity with others, except the commonest viral type (Adenovirus in this study; Respiratory Syncytial virus in others) and the seasonal incidence rate (higher in spring and summer in this study but not in others). In conclusion, most children with acute viral lower respiratory tract infection had an uneventful course and Direct IF is a reliable method for viral detection in that disease.

Balloon pulmonary valvuloplasty in infants and children: technique and immediate result.

Between 1986 and Feb. 1993, 20 patients with moderately severe isolated pulmonary stenosis underwent cardiac catheterization and balloon pulmonary valvuloplasty (BPV). Their ages ranged from 7 months to 11 years old (mean 6.2 years), their weights ranged from 8 to 45 kg (mean 14.5 kg). Immediately after BPV, the right ventricular pressure decreased from 89 +/- 21 to 46 +/- 16 mmHg (p < 0.005). The pressure gradient across the pulmonary valve reduced by 68%, from 68 +/- 23 to 24 +/- 16 mmHg (p < 0.005). There was no significant changes in both pulmonary artery pressure (19 +/- 4 versus 21 +/- 3 mmHg), and aortic pressure (102 +/- 11 versus 104 +/- 11 mmHg). Successful BPV (pulmonic pressure gradient < 36 mmHg) was achieved in 15 cases (75%). Among the 5 unsuccessful cases, 2 patients underwent redilatation which had excellent results. Another 2 patients received operations, one was a dysplastic pulmonary valve, the other was due to a gradient across the pulmonary valve > 120 mmHg before BPV. The remaining one had only 40 mmHg gradient after BPV, and he was doing well on follow-up. There were no significant complications in these series. BPV is an effective and safe procedure. It should be the treatment of choice for significant pulmonary stenosis in infants and children.

Surgical ablation of Wolff-Parkinson-White syndrome in children and young adults.

From 1988 to 1991, nine patients with structural normal heart, aged 10 to 23 (median 13 years), Wolff-Parkinson-White Syndrome patients were operated at National Taiwan University Hospital. The diagnosis was established by surface electrocardiograms recorded during sinus rhythm and tachycardia, and by complete cardiac electrophysiologic studies. The location of accessory pathways (AP) were: 4 left lateral, 3 right lateral, 1 right posteroseptal and 1 right anteroseptal AV groove. In all 6 patients with manifest WPW syndrome, the location of AP could be correctly predicted by the surface EKG delta wave polarity. In all 9 patients with WPW syndrome, intraoperative epicardial and endocardial mappings confirmed their location. Wide endocardial dissection were undertaken. No surgical morbidities or mortality was encountered except in one case which developed transient postpericardiotomy syndrome. During the follow-up (2 to 4 years), all of them were in sinus rhythm, drug free and tachycardia free. In conclusion, (a) the sites of AP and the arrhythmia mechanisms can be reliably predicted by surface EKG and catheter mapping techniques; (b) surgical cure of supraventricular tachycardia could be achieved safely in children; and (c) surgical ablation still is indicated when catheter ablation is unsuccessful, or when coexistent complex cardiac pathology requires surgical intervention in small children.

[Study on coronary artery lesions in patients with Kawasaki disease: recent 9 years' experience].

During a nine year period, two-dimensional echocardiography was used to evaluate the coronary artery lesions in 293 patients with Kawasaki disease. There were 170 males and 123 females (M: F = 1.4:1), with a mean age of 28.5 months (2 months-10 years). Patients were randomly divided into 3 groups according to different treatment regimens: group A, aspirin 60-80 mg/kg alone, 199 patient; group B, aspirin plus intravenous gamma globulin (IVGG) 400 mg/kg for 5 days, 80 patients; group C, aspirin plus a single dose of IVGG 2.0 gm/kg, 14 patients. A total of 106 patients (36.2%) had coronary artery lesions. The prevalence of coronary artery lesions in groups A, B, and C was 42.7%, 22.5% and 21.4% respectively. It was the highest in group A (P < 0.01). Coronary artery involvement occurred with equal frequency in males and females. There was a significantly greater incidence of coronary artery lessons in infants younger than 1 year of age than in older children (P < 0.05). From the serial echocardiographic studies, the coronary artery lesions occurred earliest on the 5th day of onset, with the prevalence of 23.6% in the acute stage, and 35.4% at the subacute stage. The prevalence of coronary artery abnormalities in group A was significantly higher than in group B and C at 2-3 weeks and 7-8 weeks after the onset of the fever (P < 0.01). Coronary artery lesions were further classified into 3 morphologic types: dilated form, fusiform and saccular aneurysm. The prevalence of saccular aneurysms was higher in group A than in group B and C (10.0% vs 1.2%, 0%, P < 0.01). Moreover, the regression rate was also higher in group A than the other groups (P < 0.01). Fifteen cineangiograms were performed on 14 patients and they confirmed the presence of coronary lesions in all cases. Better visualization of the lesions was achieved by cineangiography than by echocardiography, especially in the middle and distal portions of the coronary artery. In group A, a six months old boy expired, 25 days after suffering from fever, due to myocardial infarction and congestive heart failure, which was also confirmed by a postmortem examination. It appears that gamma globulin infusion especially a single high dose regimen, is more effective than the conventional aspirin therapy for Kawasaki disease. The IVGG groups are also associated with a lesser prevalence of coronary lesions, a lesser degree of severity and a greater chance of regression.

[Pulmonary artery sling: diagnosis by magnetic resonance imaging--one case report].

Pulmonary artery sling is an uncommon congenital vascular anomaly, which may cause significant respiratory morbidity resulting from an external tracheal compression during early infancy. This condition should be considered on finding a mass interposed between the trachea and the esophagus showing an anterior indentation on the esophagograms. The diagnosis is usually made by invasive methods such as bronchography, bronchoscopy, cardiac catheterization, and angiography. Magnetic resonance imaging (MRI) has now become an excellent method for diagnosing cardiovascular anomalies, but the use of MRI as a means of diagnosing pulmonary artery sling is rare. In 1988, Malmgren et al, first reported the use of MRI in three cases. Their findings suggested that two overlaping sets of axial sections might be necessary for depicting the anomaly because different parts of the left pulmonary artery are imaged in different slices. In this paper, we report a diagnostic scan image which utilizes a single axial scan and reveals the pulmonary artery sling arising aberrantly from the right pulmonary artery. We also found (a) when the pulmonary artery sling interposed between the esophagus and trachea; the trachea become stenotic below the upper one-third in LAO equivalent sagittal section; (b) the right pulmonary artery compresses the proximal part of right pulmonary bronchus, and the right upper lobe bronchus arises from the trachea independently in the coronal section. Thus, we conclude that MRI, if available, should be the first choice modality for further examination when a pulmonary artery sling is suggested by conventional radiography.