Thoracoscopic repair of esophageal atresia with a distal fistula - lessons from the first 10 operations.

INTRODUCTION: Thoracoscopic esophageal atresia (EA) repair was first performed in 1999, but still the technique is treated as one of the most complex pediatric surgical procedures. AIM: The study presents a single-center experience and learning curve of thoracoscopic repair of esophageal atresia and tracheo-esophageal (distal) fistula. MATERIAL AND METHODS: From 2012 to 2014, 10 consecutive patients with esophageal atresia and tracheo-esophageal fistula were treated thoracoscopically in our center. There were 8 girls and 2 boys. Mean gestational age was 36.5 weeks and mean weight was 2230 g. Four children had associated anomalies. The surgery was performed after stabilization of the patient between the first and fourth day after birth. Five patients required intubation before surgery for respiratory distress. Bronchoscopy was not performed before the operation. RESULTS: In 8 patients, the endoscopic approach was successfully used thoracoscopically, while in 2 patients conversion to an open thoracotomy was necessary. In all patients except 1, the anastomosis was patent, with no evidence of leak. One patient demonstrated a leak, which did not resolve spontaneously, necessitating surgical repair. In long-term follow-up, 1 patient required esophageal dilatation of the anastomosis. All patients are on full oral feeding. CONCLUSIONS: The endoscopic approach is the method of choice for the treatment of esophageal atresia in our center because of excellent visualization and precise atraumatic preparation even in neonates below a weight of 2000 g.

Management of myasthenic crisis in a child.

Myasthenia gravis is an autoimmune disorder of peripheral nervous system, leading to fluctuating muscle weakness. It is caused by circulating antibodies that block acetylcholine nicotinic postsynaptic receptors at the postsynaptic neuromuscular junction. Myasthenic crisis is a life-threatening complication, which is defined as weakness from acquired myasthenia gravis. In this paper we described a 15-year-old boy who was admitted to the Paediatric Intensive Care Unit due to myasthenic crisis. He had suffered not only from myasthenia gravis but also hypothyroidism, cerebral palsy and epilepsy. The patient required mechanical ventilation and was successfully treated with both plasmapheresis and intravenous immunoglobulins. He recovered from the crisis and then thymectomy was performed. Perioperative period and anaesthesia passed uncomplicated. Discharged home from the hospital after 2.5 month-treatment, for the last 4 years, he has only come on scheduled outpatient medical appointments. This case reveals that myasthenic crisis, albeit rare, may occur in male adolescents. In such cases multidisciplinary care followed by surgery becomes a procedure of choice. Concomitant medical problems, if well controlled, do not affect the results of outcome of the underlying disease.

[Effects of choice of anaesthesia on the patients image of the anaesthesiologist]. / Czy rodzaj znieczulenia wplywa na wizerunek lekarza anesthzjologa?

BACKGROUND: The social status of physicians has been traditionally high in Poland, over recent years, we have noticed increased patient expectations in relation to the newest technology and the highest possible competence. The patient s image of medical personnel may influence his or her opinion about the quality of the service and of the medical centre. At the same time, we have noticed signs of decreasing trust, and an increased number of legal claims against doctors. The purpose of this study was to compare the image of anaesthesiologists, as perceived by patients who underwent Caesarean section either with general or spinal anaesthesia. METHODS: Five hundred and thirteen parturients were asked to complete a questionnaire about their view of the attending anaesthesiologist, assessing the doctors attitude with 7-degree visual-analogue scale. RESULTS: Four hundred and twelve valid forms were returned. Women who received spinal anaesthesia rated their anaesthesiologist higher than those who had general anaesthesia. Among the most important factors that influenced their opinion were: competence, calmness, trustfulness, accurate and detailed information, patience and kindness. Feelings of intimacy and privacy were less important, but the length of the preoperative visit was found to be a relevant factor. Anaesthesiologists providing spinal anaesthesia were rated higher, probably because they were spending more time with awake patients than those who had chosen general anaesthesia. The latter may also have been in a hurry, because of co-existing emergencies. CONCLUSION: We conclude that patients satisfaction depends mainly on the time spent with their doctors before anaesthesia and during the procedure. Regional anaesthesia may increase the patients trust and satisfaction, when compared with general anaesthesia.

[Endotracheal suctioning in neonates and children]. / Toaleta dróg oddechowych u noworodków i dzieci leczonych w oddzialach intensywnej terapii.

Endotracheal suction is essential to keep the respiratory capacity of the bronchial tree. The aim of this study was to establish the principles reducing potential side-effects, like hypoxia, bradycardia, hypotension, arrhythmia, nosocomial infections. Analysing the literature we have selected the following major beneficial factors: 1:2 to 2:3 cathether - tracheal tube diameter ratio, individual adjustment of the suctioning frequency, maximal duration of the procedure capped at 10-15 sec., minimal effective suctioning pressure of 80-100 mmHg. We have also determined that the following procedures should be also taken into consideration: preoxygenation (only for unstable patients), sedation and analgesia. We have concluded with the comparison of the two suction systems, pointing out that, especially for unstable patients, closed-suction system proves more suitable.

[Non-invasive mandatory ventilation in extremely low birth weight and very low birth weight newborns with failed respiration]. / Nieinwazyjna wentylacja obowiazkowa u noworodków ze skrajnie niska urodzeniowa masa ciala i bardzo niska urodzeniowa masa ciala z zaburzeniami wentylacji.

Early extubation of ELBW and VLBW premature infants treated with IMV results in decreased incidence of tracheal and laryngeal injury, lowers the risk of nosocomial infection, decreases the severity and frequency of bronchopulmonary dysplasia (BPD). Due to prematurity this group of patients is especially susceptible to extubation failure because of apnoe, hypoventilation and atelectasis. In clinical practice attempt was made to provide adequate noninvasive ventilation by the use of nasal intermittent mandatory ventilation in the case of apnoe of prematurity. Advantages of noninvasive nasal IMV oppose the risk of stomach distension and regurgitation due to high tension of pylorus combined with inadequate cardia tension. The aim of study was the evaluation of noninvasive nasal IMV effectiveness along with a risk of abdominal distension caused by air trapping. 32 patients were examined during one year of studies. In all but one the use of nasal intermittent mandatory ventilation resulted in decreased incidence of apnoe of prematurity. Satisfactory levels of SaO2 and pCO2 were achieved without endotracheal tube placement, avoiding the risks of nosocomial pneumonia and bronchopulmonary dysplasia.