A clinical-pathological study of nonsurvivors of newborn ECMO.

Extracorporeal membrane oxygenation (ECMO) is an important means of supporting newborns with respiratory failure. While short- and long-term follow-up of ECMO survivors has been thoroughly addressed, there is no systematic study of nonsurvivors. Nineteen nonsurvivors of newborn ECMO with autopsy results are divided into two groups: group 1: 12 patients who had intracranial lesions as the primary cause of death (hemorrhage 8, encephalomalacia 2, infarct 2); and group 2: 7 patients with nonintracranial primary causes of death. Patients in group 1 were significantly more acidotic, hypotensive, and smaller in age and birth weight pre-ECMO. Among group 2 patients, two with diaphragmatic hernia died of primary pulmonary disease (diffuse alveolar damage, pulmonary hypoplasia and necrosis, bronchopneumonia). One of 2 patients with persistent fetal circulation (PFC) was treated with massive doses of tolazoline and suffered fatal gastrointestinal hemorrhage and ischemic necrosis of heart, spleen, testes, and adrenals. The other PFC patient had severe pulmonary interstitial fibrosis. Two patients with meconium aspiration and a patient with streptococcal sepsis had diffuse pulmonary damage and multiple organ failure (renal medullary necrosis, and infarcts of adrenal, spleen, liver). In this series, intracranial pathology was the most common cause of death in ECMO patients, related to gestational age, acidosis, hypoxia, and size, but probably unrelated to carotid ligation.

Complement activation during prolonged extracorporeal membrane oxygenation.

Short-term cardiopulmonary bypass activates the complement system, possibly resulting in pulmonary dysfunction from granulocyte aggregation and pulmonary endothelial damage. These effects may be inhibited by steroids. Prolonged extracorporeal membrane oxygenation (ECMO) is used for newborn respiratory failure, but the effects of ECMO on complement activation are unknown. Twenty-one newborn infants with respiratory failure treated with ECMO were randomly assigned to group I (control, no steroids) or group II (30 mg/kg intravenous methylprednisolone before ECMO). Depletion assays of C3 and C5 were performed in each group at intervals before and during ECMO (declining values indicate complement activation). The groups were compared for complement levels, survival, time on ECMO and on the ventilator, and total hospitalization time. Steroids significantly shortened the time on ECMO and time on the ventilator after ECMO but did not affect survival or total hospitalization time. Steroids also enhanced activation of C3 and C5. Complement activation occurs during ECMO. Steroid administration paradoxically causes earlier complement activation but shortens ECMO and ventilator times. Complement activation during ECMO is of questionable significance. The benefits of steroids during ECMO may be mediated through other mechanisms.

Acute cholecystitis after spinal fusion and instrumentation in children.

Three children developed noncalculus cholecystitis after spinal fusion and instrumentation for their spinal deformity. Two children responded to conservative therapy, and one required cholecystectomy. If diagnosed early, this complication may be successfully treated by conservative means.

A reproducible, safe jejunostomy replacement technique by a percutaneous endoscopic method.

Patients undergoing esophagogastrectomy for cancer often benefit from postoperative nutritional support and an operative jejunostomy is frequently placed at the time of surgery. If the original tube has been removed, replacement of this jejunostomy previously required repeat laparotomy. Described here is the technique of direct percutaneous endoscopic jejunostomy placement (PEJ) used in two such patients following esophagogastrectomy. This PEJ placement technique using a #16-Fr, Pezzer-type Ponsky tube is an easy, reproducible method for the replacement of an operative jejunostomy tube. The fibrosed tract between the abdominal wall and jejunum allows the safe performance of the procedure if one endoscopically identifies the site of operative insertion.

Malignancy associated with ureterosigmoidostomy: detection by mucosa ornithine decarboxylase.

Urinary diversion into the gastrointestinal tract (ureterosigmoidostomy) is associated with stepwise malignant degeneration of colonic mucosa. Early detection of such malignancy can be difficult. Ornithine decarboxylase (ODC) is an enzyme that initiates polyamine synthesis that is elevated in malignant colonic mucosa, but its level in premalignant mucosa after ureterosigmoidostomy is unknown. Ten Wistar rats underwent urinary diversion (bladder trigone to sigmoid colon), and were maintained on a regular diet with antibiotics for 6 months, then killed. All animals developed metaplastic changes histologically at the anastomosis. Mean ODC levels of colonic mucosa at the anastomosis v normal colon 8 cm proximal were 515 +/- 177 pmole v 24.5 +/- 4.4 (P less than .01). These data show that premalignant changes in colonic mucosa after ureterosigmoidostomy can be detected by elevated colonic biopsy ODC levels. Periodic sigmoidoscopy with colon mucosa biopsy for histology and ODC levels in children with ureterosigmoidostomy is recommended.

The effects of perfluorochemicals on tumor growth and chemotherapy response.

Hypoxia, leading to cells in resting or slow replication phases may be a cause of chemotherapy and radiation therapy resistance in some tumors. Perfluorochemicals (PFC) may potentiate response to these therapies by increasing oxygen delivery to the tumor, forcing cells into more therapy-responsive replicating phases. To assess the effects of PFC on tumor growth and chemotherapy response, 91 ACI rats bearing 1 cc flank Morris hepatoma tumors were divided into groups: Group I, control; Group II, Adriamycin (ADR) 10 mg/kg intraperitoneally (IP); Group III, Cytoxan (CTX) 100 mg/kg IP; Group IV, PFC 20 mL/kg IV; Group V, ADR and PFC; Group VI, CTX and PFC. Animals were kept in 0.5 FiO2 for 24 hours after treatment, and mortality and tumor volumes determined 2 weeks later. Tumor DNA turnover was measured using opposing pathways assay of 14C-thymidine uptake and degradation. In a separate group, tumor tissue pO2 was measured polarographically with an oxygen microelectrode before and after injection of PFC (20 mL/kg). The survival was significantly reduced in group IV (4%) compared with group I, control (73%). Both ADR and CTX slowed the growth of the tumor, while PFC alone significantly accelerated tumor growth. The tumor response to ADR was potentiated by the addition of PFC. These results were confirmed by DNA synthesis evaluation. The mean pO2 level prior to injection was 6.6 +/- 1.96 mmHg compared with 18.92 +/- 1.00 mmHg after PFC injection (P less than or equal to .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Exposure of the anterior spine. Technique, complications, and results in 85 patients.

The anterior approach to the spine is necessary for correction of some congenital spinal deformities and other conditions, including spinal trauma, infection, and tumor. The morbidity associated with this procedure has not been extensively reviewed in the literature. Between 1981 and 1986, 85 patients (41 male and 44 female) aged 1 to 77 years underwent anterior spinal fusion by an orthopedic or general surgery team (33 pediatric patients and 52 adult patients). Thirty-four patients had scoliosis, 8 had kyphosis, 24 had spinal trauma, 9 had tumor, and 10 had infection. Fifteen patients had restrictive lung disease diagnosed by pulmonary function testing (10 children and 5 adults). The thoracoabdominal approach was used in 50 patients, thoracotomy in 22 patients, and the lumbar approach in 10 patients. Two incisions were used in three patients. Correction was accomplished by interbody fusion in 36 patients (17 with instrumentation) and strut graft in 49 patients (6 with instrumentation). Twelve strut grafts were vascularized ribs and 37 were free ribs. Eighty-two patients survived (96 percent). Seventy-four complications occurring in 50 patients all resolved prior to discharge. These included 28 pulmonary complications, 27 urinary complications, and 5 gastrointestinal complications. Three patients required prolonged mechanical ventilation. Solid fusion was seen in 78 of 85 patients, whereas pseudoarthrosis developed in 7.