Transposition of the great arteries and intact ventricular septum: anatomical repair in the neonate

Fourteen neonates 18 hours to 32 days old with transposition of the great arteries (TGA) and virtually intact ventricular septum (IVS) underwent arterial switch operations under deep hypothermic circulatory arrest. Preoperative left ventricular to right ventricular peak systolic pressure ratios ranged from 0.7 to 1.0 (mean, 0.92), and the echocardiogram showed a centrally positioned ventricular septum in 10 patients and a rightward displaced ventricular septum in 4. One patient died twelve hours after operation. Postoperative complications included bleeding from the left coronary artery-pulmonary artery anastomosis (1 patient), stenosis of the pulmonary artery-aorta anastomosis requiring reoperation (2 patients), transient ST segment and T wave abnormalities consistent with ischemia (3), and development of pathological Q waves suggestive of clinically silent infarction (2). The capacity of the left ventricle in a neonate to effectively take over the systemic circulation was clearly demonstrated. A longer follow-up period is needed to assess late ventricular function, coronary ostial growth, growth of the aorta-pulmonary artery anastomosis, late aortic valve (anatomical pulmonary valve) function before definitive recommendations about the superiority of the arterial switch operation in neonates with TGA plus IVS can be formulated.     

Vertebral anomalies associated with esophageal atresia and tracheoesophageal fistula with reference to the initial operative mortality

In a series of 40 patients with esophageal atresia and tracheoesophageal fistula, the incidence of musculoskeletal anomalies was 45% (18 patients). An extra mesodermal segment was found in 15 patients (13 paired thoracic vertebrae and 13 paired ribs in nine patients; six lumbar vertebrae in 6 patients). The mortality in grade A infants with an extra mesodermal segment was significantly higher than in those infants with a normal spine (p > 0.01). It is suggested that segmentation or abnormal segmentation of the embryo may be important as a cause of esophageal atresia.     

Chronic exertional compartment syndrome of the forearm: a case report

A 40-year-old man sustained a circumferential crush injury to his right forearm. Four months after injury, he experienced the onset of numbness and tingling in the distribution of the median nerve after exercise. Elevated compartment pressures of the palmar forearm and slowing of median nerve conduction after exercise suggested chronic exertional compartment syndrome. A flexor fasciotomy led to complete relief of symptoms, which allowed the patient unrestricted activity.     

Differential effects of propofol, ketamine, and thiopental anaesthesia on the skeletal muscle microcirculation of normotensive and hypertensive rats in vivo

Background. This study utilized the dorsal microcirculatorychamber (DMC) model to determine differential effects of i.v.propofol, ketamine, and thiopental anaesthesia on the skeletalmuscle microcirculation (10–180 µm) of normotensive(Male Wistar Kyoto, WKY) and hypertensive (spontaneously hypertensiveHarlan, SHR) rats, importantly, comparing responses to a consciousbaseline. Methods. Three weeks following implantation of the DMC in WKY(n=8) and SHR (n=6) (130 g) 0.25 ml 100 g^–1 FITC–BSA(i.v.) was administered and the microcirculation viewed usingfluorescent in vivo microscopy for a 30 min baseline (t=0–30min). This was followed by either propofol, thiopental, ketamine,or saline (i.v. bolus induction over 5 min (t=30–35 min)),then maintenance step-up infusion for 60 min (t=45–105min), so that animals received all four agents 1 week apart(56 experiments). Results. Dilation of A3 arterioles (15–30 µm) andV3 venules (20–40 µm) with propofol was greaterin SHR (t=95 min, A3 36.7 (12)%, V3 15.5 (2.3)%) than WKY (t=95min, A3 19.4 (7.4)%, V3 8.0 (2.3)%) (P<0.05). Constrictionof A3 with ketamine was greater in SHR (t=95 min, A3 –29.1(6.4)%) than WKY (A3 –17.5 (8.8)%) (P<0.05). This wasaccompanied by hypotension with propofol in SHR (–32%decrease in systolic arterial pressure), but not WKY (–6%)and hypertension with ketamine in WKY (–15%) and SHR (–24%)(P<0.05). During thiopental anaesthesia there was dilationof A1 (80–180 µm), A3, and V3 in WKY (P<0.05).Conversely, in SHR dilation of venules (29.2 (8.7)%) was accompaniedby constriction of A1 and A3 (t=95 min, A1 –25.1 (5.9)%,A3 –45.2 (3.1)%) (P<0.05). Conclusion. Within the skeletal muscle microcirculation of hypertensiverats there is enhanced dilation with propofol and constrictionwith ketamine, associated with exaggerated changes in arterialpressure. Thus, dysfunctional control mechanisms at the levelof the microcirculation alter responses to anaesthesia duringhypertension.      

The occult neuropathic bladder

A condition of occult neuropathic bladder can be defined by clinical and radiologic investigations in which the course of the disease closely simulated that observed in the well-defined congenital neuropathies but in which ordinary neurological signs are lacking. The bethanechol stimulation test has some place in confirming this diagnosis, and bethanechol may be of value in this and other forms of neuropathic bladder.     

The ureteric orifice: the embryologic key to radiologic status of duplex kidneys.

In this study the ureteric orifice position of duplex ureters in the bladder or urethra of children was correlated with the kidney configuration as determined by x-ray examination and in some by surgical excision and biopsy.A previous study¹ of 51 necropsy speciments of duplex kidneys, ureters, and bladders of neonates, revealed a close correlation between ureteric oreteric orifice position and kidney morphology.This clinical study of children further confirms that the position and type of ureteral orifice act as guides to renal order and disorder in duplex kidneys. A radiographic classification of kidney configurrations was invoked to match and correlate form with orifice position. From this cystoradiographic study, it appears that renal abnormalities occur when ureteric buds arise from faulty locations in the Wolffian duct during embryogenesis.     

A complication of intramedullary nailing

A case is described of intramedullary nailing of the femur, complicated by non-union, fracture of the nail, pseudarthrosis, malunion and subsequent distal migration of the proximal nail fragment over a period of 8 years.     

Intussusception in the older child- suspect lymphosarcoma.

Examination of the records of 378 children with intussusception at our institution revealed that 29 cases were caused by an identifiable intestinal lesion. A Meckel's diverticulum was the causative agent in 21 children, all of whom were under 2 yr of age. A previously undiagnosed ileal lymphosarcoma produced the intussusception in six other children, all between 6 1/2 and 9 yr of age. Our experience indicates that any child over 6 yr of age with the clinical findings of colicky abdominal pain, bloody stools, and a palpable mass plus the radiographic evidence of intussusception must be considered to have ileal lymphosarcoma until proven otherwise. Hydrostatic reduction of the intussusception must be accompanied by extensive small bowel reflux of barium in order to effectively rule out a small intestinal lesion. If this is not accomplished, surgery should be planned with the suspicion that a malignancy may be present. If this suspicion is confirmed by frozen section, the operation procedure should include wide surgical excision of the lesion along with the regional lymph nodes.     

Postinfarction ventricular aneurysmectomy

Most operations performed for the treatment of ventricular aneurysm do not achieve maximal rehabilitation of the damaged heart. Cardiac surgeons generally ignore the importance of the flail septum that results from anteroseptal infarction. Many believe that the obstructed left anterior descending coronary artery must be carefully avoided during closure of the ventriculotomy incision. In addition, many surgeons believe that it is necessary to buttress all ventricular sutures with Teflon. For some reason, there seems to be a fear that the left ventricular volume will be reduced to an intolerable level after proper ventricular aneurysmectomy. Between January 1976 and December 1982, 102 patients underwent ventricular aneurysmectomy at St. Joseph's Hospital Health Center. The hospital mortality rate was 5.9 percent. The operative technique described emphasizes the need for foreshortening the fibrosed septum in an effort to minimize residual paradoxic motion. The left anterior descending coronary artery is routinely incorporated in the eversion technique; Teflon buttressing is never employed. Our surgical technique has evolved from a surgical experience that began in 1962 at the Cleveland Clinic Hospital.     

An analysis of the need for pediatric surgeons in the United States

A questionnaire study covering all major population areas in the United States indicated that pediatric surgeons and potentially capable hospitals are already well-distributed throughout the country. The estimation of need for pediatric surgeons based on the area questionnaires is close to the present number of surgeons.A computer analysis was made to project numbers of pediatric surgeons per unit population to the year 200 with differing levels of trainee output. The study indicates the 14–15 training programs are sufficient to allow for slow, modest growth of the specialty if current population trends continue.     

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.     

Comparison of xenograft and prosthesis for burn wound care

A polytetrafluoroethylene-polyurethane laminate was evaluated as a temporary wound cover and compared with porcine xenograft in a series of 22 patients. The most striking difference between the two materials was that the prosthesis was far superior to pigskin with respect to its degree of adherence and its ability to debride. Good adherence of prosthesis or pigskin was associated with later autograft success. No infections were encountered and there was no fragmentation of polyurethane foam into the wound.These initial studies indicate that this prosthetic is useful as a temporary wound dressing. Its characteristics were at least equal to those of pigskin, and in many respects, it was superior.     

Analysis of vitamin levels and deficiencies in bariatric surgery patients: a single-institutional analysis

BackgroundBariatric surgery patients are at risk for vitamin deficiencies.ObjectivesInvestigate the prevalence of deficiencies of vitamins A, B1, B12, D, and folate in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in a single institution.SettingAn academic medical center.MethodsRetrospective chart reviews of 468 bariatric surgery patients (358 SG and 110 RYGB) were analyzed for vitamin levels, calcium, and parathyroid hormone. Both preoperative and postoperative measurements were obtained.ResultsDeficiency of vitamin D was the most common, seen in 27% preoperatively. Postoperatively, RYGB patients had a higher prevalence of vitamin D deficiency than SG patients (11.5% RYGB versus 5.2% SG within the first postoperative year, and 20.3% RYGB versus 13.4% SG after 1 year). Elevated parathyroid hormone was observed in 45% of RYGB patients after 1 year postoperatively. Vitamin A deficiency was uncommon preoperatively (2.7% SG versus 1.7% RYGB), but increased after surgery (9.4% SG versus 15.9% RYGB within 1 year postoperatively, and 5.2% SG versus 7.7% RYGB after 1 year). Vitamin B1 deficiency was observed in 8.1% SG versus 1.7% RYGB patients preoperatively and increased during the first year postoperatively (SG 10.5% and RYGB 13.7%), but improved after 1 year (7.2% SG versus 5.9% RYGB). Less than 2% of Vitamin B12 deficiencies and no folate deficiencies occurred in both SG and RYGB patients.ConclusionsThe highest prevalence of vitamin B1 and A deficiencies were seen in the first year postoperatively. Vitamin B12 and folate deficiency were uncommon in our patients. Vitamin D deficiency improved after surgery, but elevated parathyroid hormone was common after RYGB.     

Surgical Treatment of Cor Triatriatum

Six patients with cor triatriatum underwent surgical correction. They ranged from 1.5 to 93 months old (mean, 22 months). Congestive heart failure was present in 3 patients. Cardiomegaly and increased pulmonary vascularity were evident roentgenographically in all patients. Cardiac cineangiography demonstrated the subdividing left atrial membrane in 5 patients and suggested the correct diagnosis by revealing an abnormal configuration of the left atrium in the other patient. The opening in the anomalous left atrial membrane was stenotic in every instance. The proximal left atrial chamber communicated with the right atrium through an atrial septal defect in 5 patients and with the systemic venous circuit through a persistent left superior vena cava in the other patient, in whom the atrial septum was intact. A right atrial–transseptal approach provided ample exposure for complete excision of the obstructing membrane and repair of the atrial septum in all patients. One patient died of low cardiac output during the early postoperative period. The other 5 are alive and well at an average of 48 months after operation.     

Etomidate-Lipuro is associated with considerably less injection pain in children compared with propofol with added lidocaine

Background. Propofol is associated with a high incidence ofinjection pain in children, even if given together with lidocaine.A new lipid formulation of etomidate (Etomidate-®Lipuro)has been found in adults to cause very little discomfort duringi.v. injection. The aim of the present prospective, double-blind,randomized trial was to compare the incidence of injection painduring i.v. induction of anaesthesia between propofol with addedlidocaine (previous standard) and this new etomidate formulationin paediatric patients. Methods. A total of 110 paediatric patients, aged 2–16years, scheduled for outpatient surgery were planned to be includedin the study. The primary end point of the study was the incidenceof injection pain during induction of anaesthesia as assessedby a four-point scale as described previously. The occurrenceof myoclonic muscular activity was registered as a secondaryend point (four-point scale). An interim analysis after 80 patientswas requested by the Ethics' Committee. Results. The study was stopped after the inclusion of 80 patients.A significantly lower incidence of injection pain was foundin the Etomidate-®Lipuro group as compared with the propofol–lidocainegroup (5.0% vs 47.5%, P<0.001). The use of etomidate wasassociated with a significantly higher incidence of myoclonicactivity compared with propofol–lidocaine (85.0% vs 15%,P<0.001). Conclusions. The use of a new lipid formulation of etomidateis associated with significantly less injection pain than propofolwith added lidocaine in children. This finding may warrant achange in clinical practice in order to avoid unnecessary painin children.     

Thermodilution cardiac output measurement in infants and small children following intracardiac surgery

A modified catheter has been used in conjunction with a thermodilution cardiac output computer for postoperative assessment of cardiac function in infants and children.Because of the small amount of fluid required for each determination and the simplicity of the technique, serial measurements can be done safely.Its use has a contributed to the early detection of low output states. It has also proven to be a useful tool for estimating the optimal heart rate in each patient and for assessing the effectiveness of therapeutic measures.     

A case of germinoma in the septum pellucidum manifesting as amnesia and hemiparesis

BACKGROUND: We report a rare case of germinoma mainly located in the septum pellucidum. CASE DESCRIPTION: A 19-year-old man presented with germinoma located in the septum pellucidum manifesting as amnesia and right hemiparesis. Magnetic resonance imaging demonstrated a heterogeneously enhanced mass in the septum pellucidum and abnormal T2-weighted signals in the left basal ganglia. An anterior transcallosal approach was performed to remove the mass in the septum pellucidum. The histological diagnosis was germinoma. Radiotherapy and chemotherapy were given. He was discharged with slight amnesia and right hemipareis. INTERPRETATION: Intracranial germinoma can arise from the septum pellucidum.     

Fracture due to shock from domestic electricity supply

This report describes a fracture-dislocation of the shoulder joint due to electric shock. This is the first case reported in an English language journal of fracture due to shock from the domestic electricity supply. Other cases have been reported but not caused by such a low voltage current.     

Dysphagia predicts greater weight regain after Roux-en-Y gastric bypass: a longitudinal case-matched study

BackgroundWeight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.ObjectivesWe hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.SettingSingle tertiary care referral center.MethodsThis was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ² and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.ResultsForty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.ConclusionsDysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.