Rescue of acute portal vein thrombosis after liver transplantation using a cavoportal shunt at re-transplantation.

BACKGROUND: Portal vein thrombosis is a rare but devastating complication following orthotopic liver transplantation. Fulminant liver failure ensues with acute portal vein thrombosis after transplantation limiting the treatment options. METHODS: We successfully re-transplanted a 46-year-old female patient who developed acute portal vein thrombosis 19 d after orthotopic liver transplantation. Vascular reconstruction included a cavoportal shunt to augment portal blood flow. RESULTS: Twelve months after re-transplantation this patient lives independently and enjoys excellent liver allograft function. CONCLUSIONS: Cavoportal shunt can augment portal blood flow in adult recipients of orthotopic liver transplants. This technique can be successfully employed during re-transplantation when portal blood flow is inadequate to maintain patency.

Transplantation of adult living donor kidneys into infants and small children.

HYPOTHESIS: We hypothesized that improved outcomes following renal transplantation in high-risk infants and small children primarily are due to advances in immunosuppression and accurate diagnosis of rejection. Optimizing renal allograft perfusion is critical to achieving good early graft function and decreasing early graft loss. DESIGN: Twenty-eight consecutive recipients (weighing <20 kg) of adult living donor kidneys transplanted at our center from 1984 to 1999 were reviewed. Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported at 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992-1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection were compared. RESULTS: Graft and patient survival in group 1 (n = 13) at 1, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, all 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejection. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient death [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and thrombosis (7.1%) were low and did not differ between groups. Percutaneous renal biopsy was used more frequently in group 2 to evaluate graft dysfunction and guide treatment. CONCLUSIONS: We conclude that improved overall graft and patient survival in group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histological diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in optimizing early graft function and decreasing vascular complications.

Delayed primary repair of esophageal atresia with tracheoesophageal fistula: is it worth the wait?

OBJECTIVE: To characterize a successful approach to the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF), significant prematurity with respiratory distress syndrome (RDS), or both, so as to preserve the native esophagus. DESIGN: A review of the medical records and office charts of a cohort of patients with EA and TEF. SETTING: A tertiary care children's hospital affiliated with a major university. PATIENTS: A total of 118 children with EA and TEF admitted from February 1986 through December 1996. All of the patients diagnosed as having EA and TEF during this period were included. INTERVENTION: Of the 118 infants, 88 received primary repair of EA and TEF within 48 hours of birth. An additional 23 children had the TEF divided and a gastrostomy placed secondary to (1) severe RDS and prematurity (n = 6), (2) long-gap EA (gap length > 4 cm or the upper pouch above the thoracic inlet (n = 10), or (3) associated cardiac defects (n = 7). Delayed primary EA repair was done when the RDS resolved or the gap length was 2 cm or less. MAIN OUTCOME MEASURES: Successful anastomosis of native esophagus. Comparison of incidence of gastroesophageal reflux, anastomotic complications, or survival between groups undergoing primary or delayed repair. RESULTS: Primary EA was accomplished in 88 patients. Delayed EA was successfully accomplished in 18 of the 19 surviving patients within 5 months, thereby preserving the native esophagus in all surviving infants. There was no difference in anastomotic complications, gastroesophageal reflux, or survival when the delayed group was compared with those who had a primary repair. CONCLUSIONS: Using delayed EA repair, all children with EA and TEF, regardless of gap length, can have their esophagus preserved. The primary cause of mortality was the association of a severe cardiac anomaly with EA and TEF.

Aortic arch anomalies associated with long gap esophageal atresia and tracheoesophageal fistula.

PURPOSE: The purpose of this study was to determine whether aortic arch anomalies are associated with long gap esophageal atresia and tracheoesophageal fistula (EA-TEF). METHODS: The authors performed a retrospective review of all infants who had EA-TEF from 1980 to 1996 at two pediatric surgery centers. Two hundred three infants who had EA-TEF were identified. RESULTS: Twelve infants were noted to have both long gap EA-TEF defined as a gap length greater than 3 cm and aortic arch anomalies. Of these 12, 7 had aberrant right subclavian arteries originating from the descending aorta. Four of the seven infants who had aberrant right subclavian artery (SCA) had gap lengths greater than 4 cm. All four had their fistulae divided initially through a right thoracotomy with primary repair performed at a later date. The remaining five infants who had long gap EA-TEF had right-sided aortic arch with aberrant left subclavian arteries. All five initially underwent exploration through the right chest. On discovery of the long gap EA and concurrent vascular anomaly, the thoracotomies were closed, and the infants underwent definitive repair of both their EA-TEF and their vascular anomaly through a left thoracotomy. CONCLUSIONS: The authors find that aortic arch anomalies are associated with long gap EA-TEF. Patients who have these two anomalies tend to have a long gap. Preoperative diagnosis of these anomalies may alter the timing and technique of surgical intervention. The embryogenesis of these vascular lesions may account for this more severe form of esophageal atresia.

Necrotizing fasciitis after Plastibell circumcision.

Necrotizing fasciitis is a potentially life-threatening infection of subcutaneous tissues and Scarpa's fascia that rarely affects neonates. We report the occurrence of this devastating infection in two neonates after routine Plastibell circumcision. These case reports highlight the presentation and management of this complication after a relatively routine and frequently performed operation. This report also emphasizes the differences between cellulitis and necrotizing fasciitis and suggests strategies for management.

The effect of endotoxin on intestinal mucosal permeability to bacteria in vitro.

OBJECTIVE: To examine the role of the intestinal mucosa in bacterial translocation, in vitro bacterial passage across ileal mucosal segments mounted in Ussing chambers were studied in control and endotoxin (lipopolysaccharide)-treated rats. DESIGN: Experimental study. MATERIALS AND METHODS: Three groups of rats were studied. The experimental group received an intraperitoneal injection of lipopolysaccharide, while controls received an equivalent volume of saline solution; a third group received no treatment. Twenty-four hours later, all groups underwent laparotomy and organ culture to assess bacterial translocation. At the same time, a segment of mucosa from the terminal ileum of each animal was mounted in a Ussing chamber, and the transmucosal passage of labeled Escherichia coli from the luminal to serosal surface was assessed by results of serial cultures. RESULTS: In vivo bacterial translocation occurred in 100% of the lipopolysaccharide-treated animals, significantly higher than the incidence seen in controls (25%; P < .05). In vitro passage of labeled E coli across ileal mucosa in the Ussing chamber occurred in 78% of lipopolysaccharide-treated animals, while in controls transmucosal passage was seen in only 14% (P < .05). Histologic examination of mucosa from both groups using light and transmission electron microscopy demonstrated no structural differences between groups. CONCLUSIONS: Increased permeability to bacteria at the mucosal level contributes to the bacterial translocation seen in endotoxemia.

Quantitative and morphologic analysis of bacterial translocation in neonates.

OBJECTIVE: To elucidate the mechanisms of bacterial translocation in animals fed a conventional formula by correlating transmucosal bacterial passage in vitro with the structural characteristics of the neonatal intestinal mucosa. DESIGN: Newborn rabbits were randomized to receive a conventional formula or breast milk. Bacterial translocation to the mesenteric lymph nodes, liver, and spleen was quantitated after 7 days, and transmucosal passage of bacteria was measured in vitro using the Ussing chamber. The mucosal membranes were examined by light, transmission electron, and confocal laser scanning microscopy. RESULTS: Bacterial passage was rarely seen in the breast milk-fed animals in contrast to the formula-fed animals. Unlike the normal-appearing membranes from breast milk-fed animals, the epithelial cells of formula-fed animals were vacuolated but healthy, with normal polarization and microvillus border by confocal laser scanning microscopy. Villi of formula-fed animals were less densely packed than those of the breast milk-fed animals. Bacterial adhesion, internalization, and transmucosal passage were seen only in membranes from formula-fed animals. Transmission electron microscopy demonstrated bacteria incorporating into the epithelial surface through an active phagocytic process, with rearrangement of the actin cytoskeleton. Once internalized, these bacteria were seen within the cytoplasmic vacuoles and subsequently in the submucosa. No bacteria passed between epithelial cells. CONCLUSION: Morphological changes in the intestinal mucosa of formula-fed newborn rabbits may increase permeability to bacteria.

Necrotizing enterocolitis in the extremely low birth weight infant.

Improved neonatal management has resulted in an enlarging population of extremely low birth weight (ELBW) infants. These infants have a high incidence of necrotizing enterocolitis (NEC) and a high mortality rate. The authors compared two groups of NEC patients: ELBW infants (< 1,000 g and/or < or = 28 weeks' gestation) and "standard" premature infants (29 to 36 weeks' gestation). NEC was classified according to the extent of bowel involvement: (1) focal, (2) diffuse, or (3) pan involvement (pan necrosis). Clinical laboratory, radiological, pathological, and bacteriologic findings, management, and mortality were analyzed. There were no significant differences between the groups with respect to gender, race, delivery mode, or incidence of prenatal or perinatal problems. The most common presenting signs in both groups were abdominal distension, vomiting, and feeding intolerance. The onset of signs and the time of first feedings were significantly later in the ELBW group. Pneumatosis was the most frequent initial radiological finding (60% of the ELBW group, 75% of the premature group). Portal vein air (PVA) was present in 29% of the ELBW and premature infants. Seventy-one percent of ELBW infants with PVA had pan involvement, versus 40% of premature infants (P < .05). There were significant differences in the peritoneal cultures between the groups. The premature group had significantly more Escherichia coli (54% v 23%). The ELBW group had a wider variety of microorganisms (eg, Clostridium sp, Pseudomonas sp, and yeast). Survival was significantly higher for the premature group (84% v 55%). The mortality rate was 93% when pan involvement was present in the ELBW group.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing persistent subjective insomnia in old age: a follow-up study of good and poor sleepers aged 65 to 74.

Of 82 subjective insomniacs aged 65-74 years identified during a community survey and classified on the basis of self-reported sleep quality, 69 (84%) continued to complain of poor sleep when re-interviewed 18-24 months later. When compared with a control group of similarly stable 'good sleepers' (n = 64) drawn from the same community sample these persistent subjective insomniacs showed significantly higher levels of constitutional (trait) and transitory (state) anxiety, and neuroticism. Discriminant analysis indicated that elevated levels of neuroticism, reduced health status (as measured by the number of drugs prescribed) and relatively high levels of tea consumption were most closely associated with persistent complaints of poor sleep. Thus, despite the existence of health problems as a major cause of sleep disturbance in later life, personality factors appear to exert a pervasive influence on subjective sleep quality among the 'younger' elderly.

Surgical management of the chronic venous ulcer: the Rob procedure.

Eighteen operations for venous ulceration were performed through a stocking seam incision with only one recurrence and minimal wound problems. The prolonged morbidity of venous ulcer disease can be alleviated with the method described. By a history and clinical examination followed by venography, a group of patients with venous ulcers can be identified who will benefit from an aggressive surgical approach.