Split abdominal wall muscle flap repair vs patch repair of large congenital diaphragmatic hernias.

PURPOSE: Large congenital diaphragmatic hernias are commonly repaired with a prosthetic patch. We hypothesized that a split abdominal wall muscle flap would reduce the risk of recurrence. METHODS: A retrospective review of neonates with congenital diaphragmatic hernia in whom primary repair was not possible was performed. Kaplan-Meier analyses and Cox proportional hazards modeling were performed. RESULTS: Of 153 patients, 46 could not have repair with primary closure of the diaphragm. Thirty-three survived to discharge and were subjected to analysis for recurrence. Ten underwent repair with a patch, whereas 23 had a muscle flap (internal oblique and transversalis) patch. The groups were similar with regard to demographics, need for extracorporeal membrane oxygenation, repair on extracorporeal membrane oxygenation, and size of the defect. Fifty percent of patch repairs recurred with a median time of 0.5 years. Only one (4.3%) of the patients who had muscle flap patch developed a recurrence. This was significant on Kaplan-Meier analysis (P = .0009) and had a hazard ratio of 14.3 on Cox regression (P = .018). Median follow-up exceeded 4 years. No children required surgery for an abdominal wall hernia. CONCLUSIONS: The split abdominal wall muscle flap allows for closure of large congenital diaphragmatic hernia defects with autologous tissue. This approach is associated with significantly fewer recurrences than patch repairs.

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late.

PURPOSE: Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution. METHODS: A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure. RESULTS: Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance. CONCLUSION: Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

A combined solid-state NMR and synchrotron X-ray diffraction powder study on the structure of the antioxidant (+)-catechin 4.5-hydrate.

Analyses combining X-ray powder diffraction (XRD) and solid-state NMR (SSNMR) data can now provide crystal structures in challenging powders that are inaccessible by traditional methods. The flavonoid catechin is an ideal candidate for these methods, as it has eluded crystallographic characterization despite extensive study. Catechin was first described nearly two centuries ago, and its powders exhibit numerous levels of hydration. Here, synchrotron XRD data provide all heavy-atom positions in (+)-catechin 4.5-hydrate and establish the space group as C2. SSNMR data ((13)C tensor and (1)H/(13)C correlation) complete the conformation by providing catechin's five OH hydrogen orientations. Since 1903, this phase has been erroneously identified as a 4.0 hydrate, but XRD and density data establish that this discrepancy is due to the facile loss of the water molecule located at a Wyckoff special position in the unit cell. A final improvement to heavy-atom positions is provided by a geometry optimization of bond lengths and valence angles with XRD torsion angles held constant. The structural enhancement in this final structure is confirmed by the significantly improved fit of computed (13)C tensors to experimental data.