Clinical parameters do not adequately predict outcome in necrotizing enterocolitis: a multi-institutional study.

OBJECTIVE: Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and mortality. Some infants recover uneventfully with medical therapy whereas others develop severe disease (that is, NEC requiring surgery or resulting in death). Repeated attempts to identify clinical parameters that would reliably identify infants with NEC most likely to progress to severe disease have been unsuccessful. We hypothesized that comprehensive prospective data collection at multiple centers would allow us to develop a model which would identify those babies at risk for progressive NEC. STUDY DESIGN: This prospective, observational study was conducted at six university children's hospitals. Study subjects were neonates with suspected or confirmed NEC. Comprehensive maternal and newborn histories were collected at the time of enrollment, and newborn clinical data were collected prospectively, thereafter. Multivariate logistic regression analysis was used to develop a predictive model of risk factors for progression. RESULT: Of 455 neonates analyzed, 192 (42%) progressed to severe disease, and 263 (58%) advanced to full feedings without operation. The vast majority of the variables studied proved not to be associated with progression to severe disease. A total of 12 independent predictors for progression were identified, including only 3 not previously described: having a teenaged mother (odds ratio, OR, 3.14; 95% confidence interval, CI, 1.45 to 6.96), receiving cardiac compressions and/or resuscitative drugs at birth (OR, 2.51; 95% CI, 1.17 to 5.48), and having never received enteral feeding before diagnosis (OR, 2.41; 95% CI, 1.08 to 5.52). CONCLUSION: Our hypothesis proved false. Rigorous prospective data collection of a sufficient number of patients did not allow us to create a model sufficiently predictive of progressive NEC to be clinically useful. It appears increasingly likely that further analysis of clinical parameters alone will not lead to a significant improvement in our understanding of NEC. We believe that future studies must focus on advanced biologic parameters in conjunction with clinical findings.

Surgery-associated complications in necrotizing enterocolitis: A multiinstitutional study.

PURPOSE: This study was designed to evaluate the wound and stomal complication rate associated with surgical intervention in infants with necrotizing enterocolitis (NEC). METHODS: Comprehensive demographic and perioperative data were collected prospectively from 4 separate university hospitals on 51 infants with surgically treated NEC. The postoperative complication rate included wound (infection, dehiscence) and stomal (prolapse, retraction, necrosis, stricture) problems. For analysis, patients were grouped based on gestational age less than 28 weeks (group I, n = 30) and >/=28 weeks (group II, n = 21). Z-score analysis was used for intergroup evaluation. RESULTS: Significantly more infants in group I (21 of 30 [70%] versus group II, 6 of 21 [29%]; P <.001) were treated initially with Penrose drainage alone, but most eventually underwent laparotomy (group I, 28 of 30 [93%] versus group II, 19 of 21 [91%]; P value, not significant). The combined stomal/wound complication rate was significantly higher in group I (14 of 30 [47%]) versus group II (6 of 21 [29%]; P <.025). Of 51 patients, one operation was required in 23 (45%), 2 in 18 (35%), 3 in 8 (16%), and 4 in 2 (4%). CONCLUSIONS: Although the stomal/wound complication rate was significantly higher in group I, both groups had very substantial complication rates, emphasizing the vulnerability of this infant population. Parents, especially of very premature babies, should be advised that multiple operations are likely and that complications should be expected.

Nutritional morbidity in survivors of congenital diaphragmatic hernia.

PURPOSE: The purpose of this report is to detail the nutritional sequelae seen in survivors of congenital diaphragmatic hernia (CDH) followed in a multidisciplinary clinic. METHODS: Data on 121 surviving CDH patients seen between 1990 and 2000 were collected. Regression analysis was used to determine the impact of factors such as Apgar score, birth weight, extracorporeal membrane oxygenation (ECMO), and patch repair on outcomes associated with nutritional morbidity. RESULTS: There were 100 left and 21 right CDH defects. Mean birth weight and 5-minute Apgar score were 3.1 kg (+/-0.8) and 6.8(+/-2), respectively. Extracorporeal membrane oxygenation was required in 43 (36%) patients and patch repair in 39 (32%). A gastrostomy was required in 39 (32%) patients and a fundoplication in 23 (19%) patients. The side of the defect did not affect the frequency of these procedures. Fifty-six percent of patients were below the 25th percentile for weight during most of their first year. Regression analysis found that duration of ventilation (P <.001) and the presence of a patch repair (P =.03) were independent variables predictive of failure to thrive thereby requiring a gastrostomy tube. Patch repair also was predictive of need for subsequent fundoplication caused by gastroesophageal reflux (P <.001). Twenty-nine patients (24%) had severe oral aversion. Risk factors were prolonged ventilation (P =.001) and oxygen requirement at discharge (P =.015). Two thirds of these patients subsequently improved. CONCLUSIONS: Nutritional problems continue to be a source of morbidity for survivors of CDH, particularly in the first year of life. Not surprisingly, patients who had prolonged intubation and prosthetic material at the gastroesophageal junction fared worse. Despite aggressive nutritional management, 56% of the population remained below the twenty-fifth percentile for weight. These data show the need for careful nutritional assessment in all CDH patients, especially those at high risk for malnutrition.

Nutritional and other postoperative management of neonates with short bowel syndrome correlates with clinical outcomes.

OBJECTIVE: To determine correlates of clinical outcomes in patients with short bowel syndrome (SBS). METHODS: Retrospective medical record review of neonates treated between 1986 and 1998 who met our criteria for SBS: dependence on parenteral nutrition (PN) for at least 90 days after surgical therapy for congenital or acquired intestinal diseases. RESULTS: Thirty subjects with complete data were identified; 13 (43%) had necrotizing enterocolitis, and 17 (57%)had intestinal malformations. Mean (SD) residual small bowel length was 83 (67) cm. Enteral feeding with breastmilk (r = -0.821) or an amino acid-based formula (r = -0.793) was associated with a shorter duration of PN, as were longer residual small bowel length (r = -0.475) and percentage of calories received enterally at 6 weeks after surgery(r = -0.527). Shorter time without diverting ileostomy or colostomy (r = 0.400), enteral feeding with a protein hydrolysate formula (r = -0.476), and percentage of calories received enterally at 6 weeks after surgery (r = -0.504) were associated with a lower peak direct bilirubin concentration. Presence of an intact ileocecal valve and frequency of catheter-related infections were not significantly correlated with duration of PN. In multivariate analysis, only residual small bowel length was a significant independent predictor of duration of PN, and only less time with a diverting ostomy was an independent predictor of peak direct bilirubin concentration. CONCLUSIONS: Although residual small bowel length remains an important predictor of duration of PN use in infants with SBS, other factors, such as use of breast milk or amino acid-based formula, may also play a role in intestinal adaptation. In addition, prompt restoration of intestinal continuity is associated with lowered risk of cholestatic liver disease. Early enteral feeding after surgery is associated both with reduced duration of PN and less cholestasis.

Primary peritoneal drainage for increasing ventilatory requirements in critically ill neonates with necrotizing enterocolitis.

BACKGROUND/PURPOSE: Primary peritoneal drainage (PPD) is an established therapy for premature neonates with necrotizing enterocolitis (NEC) and free intraperitoneal air. This study seeks to evaluate the efficacy of PPD in ill premature neonates with severe abdominal distension and increasing ventilatory requirements without free intraperitoneal air. METHODS: Eleven neonates (gestational age, 27 +/- 0.59 weeks; age, 25 +/- 4.3 days; birth weight, 862 +/- 67 g) with NEC underwent bedside PPD under local anesthesia for rapid clinical deterioration characterized by severe abdominal distension and increasing ventilatory requirements. None showed radiographic evidence of free intraperitoneal air. Mean airway pressure (MAP) and oxygenation-index (OI) were analyzed 24 hours before, immediately before and 24 hours after surgery. The patients were followed up to discharge from hospital. Statistical analyses were performed using analysis of variance (ANOVA) for repeated measures. RESULTS: Mean airway pressure (MAP) showed a significant difference (P <.05) increasing from 7.1 +/- 0.75 cm H2O 24 hours before surgery to 11 +/- 1.3 cm H2O immediately before surgery and decreasing to 9.9 +/- 1.1 cm H2O 24 hours after drainage. Likewise, OI measured at the same time intervals showed significant differences (P <.05) deteriorating from 5 +/- 1.2 to 26 +/- 6.9 then improving to 13 +/- 3.5. A significant quadratic effect (P <.03) was evident for MAP and OI (ie, values significantly rose then fell). There were six 30-day survivors (55%), and 3 survived to discharge (27%). Of the long-term survivors, 2 required operative fistula closure, and 1 needed no further surgery. CONCLUSION: Bedside PPD for increasing ventilatory requirements and abdominal distension in critically ill neonates with nonperforated NEC is a simple technique that offers rapid stabilization, although ultimate mortality rate remains high.

Do critically ill surgical neonates have increased energy expenditure?

BACKGROUND/PURPOSE: Adult metabolic studies suggest that critically ill patients have increased energy expenditures and thus require higher caloric allotments. To assess whether this is true in surgical neonates the authors utilized a validated, gas leak-independent, nonradioactive, isotopic technique to measure the energy expenditures of a stable postoperative group and a severely stressed cohort. METHODS: Eight (3.46+/-1.0 kg), hemodynamically stable, total parenteral nutrition (TPN)-fed, nonventilated, surgical neonates (5 with gastroschisis, 2 with intestinal atresia, and 1 with intestinal volvulus) were studied on postoperative day 15.5+/-11.9. These were compared with 10 (BW = 3.20+/-0.2 kg), TPN-fed, extracorporeal life support (ECLS)-dependent neonates, studied on day of life 7.0+/- 2.8. Energy expenditure was obtained using a primed, 3-hour infusion of NaH(13)CO(3'), breath (13)CO(2) enrichment determination by isotope ratio mass spectroscopy, and the application of a standard regression equation. Interleukin (IL)-6 levels and C-reactive protein (CRP) concentrations were measured to assess metabolic stress. Comparisons between groups were made using 2 sample Student's t tests. RESULTS: The mean energy expenditure was 53+/-5.1 kcal/kg/d (range, 45.6 to 59.8 kcal/kg/d) for the stable cohort and 55+/-20 kcal/kg/d (range, 32 to 79 kcal/kg/d) for the ECLS group (not significant, P =.83). The IL-6 and CRP levels were significantly higher in the ECLS group (29 +/-11.5 v 0.7+/-0.6 pg/mL [P<.001], and 31+/-22 v 0.6+/-1.3 mg/L [P<.001], respectively). Mortality rate was 0% for the stable postoperative patients and 30% for the ECLS group. CONCLUSIONS: Severely stressed surgical neonates, compared with controls, generally do not show increased energy expenditures as assessed by isotopic dilution methods. These data suggest that the routine administration of excess calories may not be warranted in critically ill surgical neonates and support the hypothesis that neonates obligately redirect energy, normally used for growth, to fuel the stress response. This is a US government work. There are no restrictions on its use.

Pulmonary morbidity in 100 survivors of congenital diaphragmatic hernia monitored in a multidisciplinary clinic.

BACKGROUND/PURPOSE: In 1990, the authors began a multidisciplinary follow-up clinic for congenital diaphragmatic hernia (CDH) patients. Although the nonpulmonary complications associated with CDH have been reported previously from this clinic, the purpose of this report is to detail the pulmonary outcome in survivors of CDH with severe pulmonary hypoplasia. METHODS: Between 1990 and 1999, one hundred patients were seen in the clinic. Before hospital discharge, all patients had baseline tests performed, which were repeated per protocol at clinic during follow-up. The data were analyzed by regression analysis to identify and determine the impact of factors on outcomes associated with the long-term pulmonary morbidity. RESULTS: The average birth weight was 3.16 kg (+/-0.7) with a mean Apgar score of 7 (+/- 2) at 5 minutes. Forty-one patients had an antenatal diagnosis performed. Extracorporeal membrane oxygenation (ECMO) was utilized in 29 patients, and a patch repair was required in 32, whereas 16 patients received both. Average time to extubation was 20.7 (+/- 20) days and mean time to discharge was 59.7 (+/- 61) days. Regression analysis showed that both the need for ECMO and a patch repair were independent predictors of delay in extubation (P <. 001, R(2) = 36%), and delay in discharge from the hospital (P =.001, R(2) = 29%). ECMO also was significantly correlated with the need for diuretics at discharge (P <.001, R(2) = 18%), and with the presence of left-right mismatch (P =.009, R(2) = 9%) and V/Q mismatch (P =.005, R(2) = 11%) on subsequent pulmonary ventilation-perfusion examinations. Sixteen patients required O(2) at discharge, and diuretics were necessary in 43 patients. Seventeen patients at discharge required bronchodilators, and during the first year an additional 36 required at least transient therapy. Similarly, 6 patients at discharge required steroids, and an additional 35 patients required at least transient therapy during the first year. Chest x-rays, although frequently abnormal, had little correlation with clinical outcome, but did influence medical therapy. V/Q scans had limited utility in patient management, and the presence of V/Q mismatch was not highly specific for future obstructive airway disease. Nevertheless, V/Q mismatch was sensitive for obstructive airway disease assessed by spirometry. Twenty-five patients over 5 years of age performed pulmonary function tests (PFTs), which showed 72% normal PFT results and 28% with evidence of obstructive airway disease. Before January 1997, 2 of 8 patients who required urgent treatment in the emergency department (ED) were admitted to the intensive care unit (ICU) secondary to acute respiratory distress. After the implementation of respiratory syncytial viral prophylaxis in January 1997, 8 patients were treated in the ED for acute respiratory distress, but none required admission to the ICU. CONCLUSIONS: Pulmonary problems continue to be a source of morbidity for survivors of CDH long after discharge. The need for ECMO and the presence of a patch repair are both predictive of more significant morbidity, but the data clearly show that non-ECMO CDH survivors also require frequent attention to pulmonary issues beyond the neonatal period. These data show the need for long-term follow-up of CDH patients preferably with a multidisciplinary team approach.

Ligation of a patent ductus arteriosus under fentanyl anesthesia improves protein metabolism in premature neonates.

BACKGROUND/PURPOSE: Although surgical ligation effectively reverses the cardiopulmonary failure associated with patent ductus arteriosus (PDA), previous findings have suggested that such surgery itself elicits a catabolic response in premature neonates. Therefore, the authors sought to quantitatively assess whether PDA ligation under fentanyl anesthesia aggravated or improved the protein metabolism of premature neonates. METHODS: Seven ventilated, premature neonates (birth weight 815 +/- 69 g) underwent PDA ligation with standardized fentanyl anesthesia (15 microg/kg) on day-of-life 8.4 +/- 1.2 and were studied immediately pre- and 16 to 24 hours postoperatively while receiving continuous total parenteral nutrition (TPN). Whole-body protein kinetics were calculated using intravenous 1-[13C]leucine, and skeletal muscle protein breakdown was measured from the urinary 3-methylhistidine to creatinine ratio (MH:Cr). RESULTS: Whole-body protein breakdown (10.9 +/- 1.2 v8.9 +/- 0.8 g/kg/d, P < .05), turnover (17.4 +/- 1.2 v 15.4 +/- 0.8 g/kg/d, P< .05), and MH:Cr (1.95 +/- 0.20 v 1.71 +/- 0.16 micromol:mg, P< .05) decreased significantly after operation. This resulted in a 60% improvement in protein balance (1.6 +/- 0.8 v 2.6 +/- 0.6 g/kg/d, P = 0.08) postoperatively. CONCLUSIONS: Because of decreased whole-body protein breakdown, whole-body protein turnover, skeletal muscle protein breakdown, and increased protein accrual, surgical PDA ligation under fentanyl anesthesia promptly improves the protein metabolism of premature neonates enduring the stress of a PDA.

Validation of a [13C]bicarbonate tracer technique to measure neonatal energy expenditure.

The use of a stable isotope-labeled [13C]bicarbonate infusion to measure energy expenditure is advantageous, as a complete collection of expired air is not required. This technique allows for facile measurements of energy expenditure in intubated neonates. The aim of the present study was to determine the accuracy of energy expenditure estimates in postsurgical neonates by using the [13C]bicarbonate method compared with the current standard, indirect calorimetry. Eight neonates who were receiving total parenteral nutrition [98 +/- 21 (SD) kcal x kg(-1) x d(-1); 3.1 +/- 0.7 (SD) protein g x kg(-1) x d(-1)] were studied on postoperative d 15.5 +/- 11.9. A primed continuous 3-h intravenous infusion of NaH13CO3 and indirect calorimetry were performed simultaneously. Energy expenditure was calculated separately from the Weir equation and from the dilution of 13CO2 in the breath in combination with the individual energy equivalents of CO2 from the diet. The rate of CO2 appearance and energy expenditure calculated from the bicarbonate method (0.725 +/- 0.021 mol x kg(-1) x d(-1); 89.5 +/- 2.5 kcal x kg(-1) x d(-1)) highly correlated (r = 0.94 and 0.98, respectively) with the CO2 excretion and energy expenditure determined by indirect calorimetry (0.489 +/- 0.016 mol x kg(-1) x d(-1); 60.2 +/- 2.0 kcal x kg(-1) x d(-1)) when analyzed nonproportionately to weight. Bland-Altman analysis demonstrated the 95% confidence interval to be +/- 8.2 kcal x kg(-1) x d(-1). Linear regression analysis revealed a highly statistically significant equation relating the two energy expenditures: Indircal (kcal/d) = -9.341 + [0.705 x Bicarb (dcal/d)]; p < 0.001, r2 = 96.4%. We conclude that energy expenditure in neonates can be accurately determined using the [13C]bicarbonate method and a regression equation. Therefore, the bicarbonate method may be useful for determining energy expenditure in neonates not readily accessible to indirect calorimetry, such as those being mechanically ventilated or on extracorporeal life support.

American Academy of Pediatrics. Committee on Nutrition. Calcium requirements of infants, children, and adolescents.

This statement is intended to provide pediatric caregivers with advice about the nutritional needs of calcium of infants, children, and adolescents. It will review the physiology of calcium metabolism and provide a review of the data about the relationship between calcium intake and bone growth and metabolism. In particular, it will focus on the large number of recent studies that have identified a relationship between childhood calcium intake and bone mineralization and the potential relationship of these data to fractures in adolescents and the development of osteoporosis in adulthood. The specific needs of children and adolescents with eating disorders are not considered.

The determinants of protein catabolism in neonates on extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Protein catabolism appears to be markedly elevated among neonates on extracorporeal membrane oxygenation (ECMO). The aim of this study was to determine the effect of dietary caloric intake on protein catabolism in neonates on ECMO to help construct therapies that may promote anabolism. METHODS: Twelve total parenteral nutrition (TPN)-fed (88.1 +/- 5.0 [SE] kcal/kg/d; range, 60 to 113 kcal/kg/d; 2.3 +/- 0.2 g/kg/d protein) neonates were studied on ECMO at day of life 7.2 +/- 0.8 d. Protein kinetics were determined using infusions of NaH13CO3 and 1-[13C]leucine. RESULTS: As expected, C-reactive protein levels were significantly elevated compared with normal controls (44.0 +/- 7.6 mg/L v 1.9 +/- 1.1 mg/L; P < .001). Negative protein balance (-2.3 +/- 0.6 g/kg/d; range, 1 to -6.4 g/kg/d) highly correlated (r = -0.88, P < .001) with total protein turnover. Increased dietary caloric intake correlated with increased amino acid oxidation (r = 0.85, P < .001), increased total protein turnover (r = 0.73, P < .01), continued negative protein balance (r = 0.72, P < .01), increased whole-body protein breakdown (r = 0.66, P < .05), and increased CO2 production rate (r = 0.73, P < .01). CONCLUSIONS: A surplus of dietary caloric intake does not improve protein catabolism and merely increases CO2 production in these highly stressed neonates. Thus, judicious caloric supplementation is warranted.

The metabolic needs of critically ill children and neonates.

The pediatric metabolic response to injury and operation is proportional to the degree of stress and causes an increase in the turnover of proteins, fats, and carbohydrates. Thereby, substrates are made readily available for the immune response and wound healing. Because this process requires energy, the resting energy expenditure of ill patients increases. Whole-body protein degradation rates are elevated out of proportion to synthetic rates, and negative protein balance also ensues. Neonates and children are particularly susceptible to the loss of lean body mass and its attendant increased morbidity and mortality caused by an intrinsic lack of endogenous stores and greater baseline requirements. An appropriately designed mixed fuel system of nutritional support replete in protein does not quell this metabolic response but can result in anabolism and continued growth in ill children. In addition, the use of adequate analgesia and anesthesia is a readily available and proven means of reducing the magnitude of the catabolism associated with operation and injury. Finally, as hormonal- and cytokine-mediated metabolic alterations are better understood, therapeutic interventions may become available to directly modulate the metabolic response to illness, thus potentially further improving clinical outcome in pediatric surgical patients.

Treatment of acute neonatal vascular injuries--the utility of multiple interventions.

BACKGROUND/PURPOSE: Vascular injuries in neonates are a rare complication of the varied invasive procedures performed in these small children. Unfortunately there remains a reluctance to repair these injuries early, often because of the relative small size of the affected vessels and the nature of the patient's underlying medical condition. The authors report a consecutive series of patients treated for arterial and venous injuries early in their course using a variety of microsurgical techniques. METHODS: A retrospective chart review was performed of consecutive patients (n = 7) treated over a 2-year period. All had injury as a result of invasive procedures performed in the neonatal period. Both arterial and venous injuries that required some form of intervention were included. RESULTS: Five arterial and two venous injuries were identified. Surgical thrombectomy and microvascular repair was required in two patients. Primary healing occurred despite prolonged (>13 hours) warm ischemia time. Pseudoaneurysms of the brachial artery and radial artery were controlled with surgical ligation, and one patient required bilateral fasciotomies for compartment syndromes related to severe spasm of the common femoral arteries. Phlegmasia cerulea dolens of the lower extremity (n = 2) was treated with leech therapy. All patients healed without tissue loss or functional deficit. CONCLUSIONS: A variety of microvascular interventions have application to the treatment of acute vascular injuries in neonates. Early, aggressive use of these techniques can provide effective therapy for these potentially devastating injuries and allow for complete limb recovery without tissue loss.

Postoperative ad lib feeding for hypertrophic pyloric stenosis.

PURPOSE: The aim of this study was to compare three methods of postoperative feeding after pyloromyotomy for hypertrophic pyloric stenosis (HPS). METHODS: The authors reviewed retrospectively the charts of 308 patients who underwent pyloromyotomy for HPS from 1984 to 1997. Nineteen patients had prolonged hospitalization for other reasons and were excluded from the study, leaving 289 patients for analysis. All procedures were performed by a single group of pediatric surgeons. The individual preferences of these surgeons resulted in three different feeding schedules: R, strictly regimented (>12 hours nothing by mouth, then incremental feeding over > or =24 hours), I, intermediate (>8 hours nothing by mouth, then incremental feeding over <24 hours), or A, ad lib (< or =4 hours nothing by mouth, with or without a single small feeding, then ad lib feedings). RESULTS: Of the 289 patients, 248 (80.5%) were boys. The average age of the patients was 5.64 weeks (range, 1 to 21 weeks). A total of 265 of 289 (92%) were full term. Thirty-nine of 289 (13.5%) had a family history positive for pyloric stenosis. A total of 104 of 289 (36%) were first-born infants, 89 of 289 (31%) were second born. The diagnosis of pyloric stenosis was made by a combination of physical examination findings and diagnostic image for most patients. An "olive" was palpated in 60.6% of the patients. Sixty percent (60.4%) of patients had an upper gastrointestinal series performed, and 42.5% were examined by ultrasonography. Overall, 53% of the patients had postoperative emesis. Only 3.5% had emesis that persisted greater than 48 hours after surgery. Patients fed ad lib after pyloromyotomy had slightly more emesis (2.2 A v. 1.2 R, and 0.7 I episodes, P = .002), but tolerated full feedings sooner than patients fed with a regimented or intermediate schedule. No patient required additional therapy or readmission after tolerating two consecutive full feedings, suggesting that this might be a suitable discharge criterion for most patients with HPS.

Tracheobronchial mucoepidermoid carcinoma in childhood and adolescence: case report and review of the literature.

In children and adolescents, primary neoplasms of the tracheobronchial tree and lungs are rare, with most tumors involving the respiratory system being metastatic, small, blue cell tumors of childhood. Of the primary pulmonary neoplasms, most are malignant with mucoepidermoid carcinoma representing about 10% of these malignant tumors. We present an 8-year-old Hispanic male with hemoptysis and several episodes of pneumonia which initially was thought to be infectious upon biopsy during bronchoscopy, but proved to be mucoepidermoid carcinoma of the tracheobronchial tree by microscopic examination during an open lung biopsy. This rare tumor is more common in adults than in children, and infrequently presents with hemoptysis. Mucoepidermoid tumors of the tracheobronchial tree carry a more favorable prognosis in children than adults. In the adult population, the overall mortality is slightly less than 30%. In contrast, of the 31 reported cases of tracheobronchial mucoepidermoid carcinoma in pediatrics, all children are free of tumor involvement with a mean follow-up period of 5.8 years (range, 0.7-21 years). Based upon the available clinical outcome and survival data, it would appear that tracheobronchial mucoepidermoid carcinoma may be successfully managed by surgical intervention alone in children and adolescents.

Utility of daily head ultrasonography for infants on extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Intracranial hemorrhage (ICH) is a major concern during extracorporeal membrane oxygenation (ECMO). Daily cranial ultrasonography has been used by many ECMO centers as a diagnostic tool for both detecting and following ICH while infants are on bypass. The purpose of this patient review was to look at the usefulness of performing daily cranial ultrasonography (HUS) in infants on ECMO in detecting intraventricular hemorrhage of a magnitude sufficient to alter patient treatment. METHODS: The authors reviewed retrospectively all of the records of all neonates treated with ECMO at the Hermann Children's Hospital, Wilford Hall USAF Medical Center, Cincinnati Children's Hospital, The University of Texas Medical Branch at Galveston, and Texas Children's Hospital between February 1986 to March 1995. Two hundred ninety-eight patients were placed on ECMO during this period. All patients had HUS before, and daily while on ECMO, and all were reviewed by the staff radiologists. A total of 2,518 HUS examinations were performed. RESULTS: Fifty-two of 298 patients (17.5%) had an intraventricular hemorrhage seen on ultrasound scan. Nine of 52 patients (17.3%) had an ICH seen on the initial HUS examination before ECMO, all of which were grade I, and 43 of 52 patients (82.7%) had ICH while on ECMO. Of these ICH, 15 were grade I, 10 were grade II, 10 were grade III, and eight were grade IV. Forty of these ICH (93%) were diagnosed by HUS during the first 5 days of the ECMO course. Seven hundred eighty-six HUS were performed after day 5, at an estimated cost of $300,000 to $450,000 (charges), demonstrating three new intraventricular hemorrhages, one grade I, and one grade IV on day 7 and one grade I on day 8. Eight patients were taken off ECMO because of ICH diagnosed within the first 5 days. One patient was taken off ECMO because of ICH diagnosed after 5 days. This patient had clinical symptoms suggestive of ICH. CONCLUSIONS: Almost all ICH occur during the first 5 days of an ECMO course. Unless there is a clinical suspicion, it is not cost effective to perform HUS after the fifth day on ECMO, because subsequent HUS examinations are unlikely to yield information significant enough to alter management.

Current surgical management of congenital diaphragmatic hernia: a report from the Congenital Diaphragmatic Hernia Study Group.

BACKGROUND: Repair of congenital diaphragmatic hernia (CDH) has changed from an emergent procedure to a delayed procedure in the last decade. Many other aspects of management have also evolved since the first successful repair. However, most reports are from single institutions. The lack of a large multicenter database has hampered progress in the management of congenital diaphragmatic hernia (CDH) and makes determination of the current standard difficult. METHODS: The CDH study group was formed in 1995 to collect data from multiple institutions in North America, Europe, and Australia. Participating centers completed a registry form on all live-born infants with CDH during 1995 and 1996. Demographic information, data about surgical management, and outcome were collected for all patients. RESULTS: Sixty-two centers participated, with 461 patients entered. Overall survival was 280 of 442 patients (63%) where survival was recorded. The defect was left-sided in 78%, right-sided in 21%, and bilateral in 1%. A subcostal approach was used in 91% of patients, with pleural drainage used in 76%. A patch of some kind was used in just over half (51%) of the patients, with polytetrafluoroethylene being the most commonly used material (81%) in those patients with a patch. The mean surgical time was 102 minutes, with an average blood loss of 14 mL (range, 0 to 500 mL). The overwhelming majority of patients underwent repair between 6:00 AM and 6:00 PM (289 of 329, 88%). Nineteen percent of patients had surgical repair on extracorporeal membrane oxygenation (ECMO) at a mean time of 170 hours into the ECMO course (range, 10 to 593 hours). The mean age at surgery in patients not treated with ECMO was 73 hours (range, 1 to 445 hours). CONCLUSIONS: The multicenter nature of this report makes it a snapshot of current management. The data would indicate that prosthetic patching of the defect has become common, that after-hours repair is infrequent, and that delayed surgical repair has become the preferred approach in many centers. Furthermore, the mean survival rate of 63% indicates that despite decades of individual effort, the CDH problem is far from solved. This highlights the need for a centralized database and cooperative multicenter studies in the future.

Laparoscopic evaluation of the pediatric inguinal hernia--a meta-analysis.

BACKGROUND/PURPOSE: For over 50 years there has been debate over how to manage the contralateral groin in children who present with a unilateral inguinal hernia. Many preoperative and intraoperative tools to diagnose a contralateral patent processus vaginalis or true inguinal hernia have been described. In 1992 laparoscopy was introduced as a new diagnostic test. Although multiple series have assessed this new tool, none of them have been able to statistically show that laparoscopy is effective in assessing the contralateral groin. By combining all published studies and using the technique of meta-analysis, intraoperative laparoscopy can be shown to be effective in diagnosing a contralateral patent processus vaginalis in children undergoing unilateral inguinal herniorrhaphy. METHODS: All available studies of children with a unilateral hernia who had exploration of the contralateral groin by laparoscopy were reanalyzed. Sensitivity and specificity of laparoscopy was determined using open exploration or development of a metachronous hernia as the gold standard. RESULTS: Nine hundred sixty-four patients were suitable for analysis. A contralateral hernia was seen on laparoscopy in 376 patients. All of these patients underwent open contralateral exploration. A patent processus vaginalis or true hernia sac was found in 373. The sensitivity of laparoscopy was 99.4% (95% confidence interval 97.87 to 99.91). Five hundred eighty-eight patients had a laparoscopy with negative results. Sixty-two of these patients then had open contralateral exploration. In one case, a patent processus vaginalis was found; the other 61 patients underwent exploration with negative results. In the remaining 526 laparoscopy-negative patients, follow-up (1 month to 3 years) was used to see if a contralateral hernia developed. A metachronous hernia developed in one of the 526 patients. The specificity of laparoscopy was 99.5% (95% confidence interval 98.39 to 99.87). Laparoscopy added an average of 6 minutes to the surgical time and was accurate regardless of the technique. There were two minor complications related to laparoscopy and no deaths. CONCLUSIONS: Laparoscopy may be the ideal tool to diagnose a contralateral patent processus vaginalis intraoperatively. It is sensitive, specific, fast, and safe. Although the presence of a patent processus does not imply that the patient will go on to develop a metachronous hernia, identifying and ligating a patent processus should certainly prevent the development of an indirect inguinal hernia.

Meta-analysis of the risk of metachronous hernia in infants and children.

BACKGROUND: Inguinal herniorrhaphy is the most common general surgical procedure performed in children. The presence of a contralateral patent processus vaginalis forms the basis of the recommendation for contralateral exploration in patients undergoing unilateral herniorrhaphy. However, a patent processus vaginalis does not necessarily go on to become a clinically apparent inguinal hernia. METHODS: All published pediatric series, in which patients underwent unilateral inguinal hernia repair and were evaluated for the development of a metachronous hernia, were included. The incidence of and risk factors associated with development a metachronous hernia were evaluated with meta-analysis. RESULTS: There were 15,310 patients ranging in age from birth to 16 years, including premature infants. Of these, 1,062 patients (7%) developed a metachronous hernia. Gender and age were not risk factors. There was an 11% risk of metachronous hernia if the original hernia was on the left side, a risk that was 50% greater than if the original hernia was on the right. Of patients who developed a metachronous hernia, 90% did so within 5 years. The complication rate of metachronous hernia was 0.5%. CONCLUSION: There is no role for routine contralateral groin exploration. High-risk infants and children, especially those who undergo left inguinal herniorrhaphy, may benefit from contralateral groin exploration. If a patent processus vaginalis is found, it should be ligated. Patients who do not undergo contralateral groin exploration should be followed up for 5 years.