Establishment of an Ex Vivo Lung Perfusion Model Using Non-Heart-Beating Large Pigs

Background

Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater.

Objective

To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death.

Materials and Methods

Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours.

Results

In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion.

Conclusion

We successfully completed EVLP using lungs from large pigs.     

Retropleural teratoma presenting as an abdominal mass in a 9-month-old boy

Background

Teratomas are rare tumors that present most commonly in the anterior mediastinum and retroperitoneum. To date, the retropleural primary site has not been reported.

Case Presentation

A 9-month-old boy presented with a large, painless, right-sided abdominal mass. Laboratory values, including tumor markers α-fetoprotein and β-human chorionic gonadotropin, were within normal limits. Diagnostic imaging, including abdominal ultrasound, computed tomographic scan, and magnetic resonance imaging, suggested a large retroperitoneal mass consistent with a teratoma. Because the mass was thought to be arising from the retroperitoneum, an abdominal approach was chosen. After adequate exposure, it became clear that the tumor was arising from above the diaphragm. The diaphragm was incised, and the pleural cavity was entered. The tumor was found in the retropleural space where it was dissected away from the inferior vena cava, aorta, and chest wall. The patient recovered without complications.

Results

Histologic examination revealed a mature cystic teratoma with no malignant features. The patient has been disease-free at 7-year follow-up, based upon both clinical examination and diagnostic imaging.

Conclusion

This is the first case report of a teratoma arising from the retropleural space. Preoperative imaging may be inaccurate for guiding surgical planning because the diaphragm may not be clearly visualized with current diagnostic techniques. Surgeons should be cautious regarding the location of tumors that arise near the diaphragm and should plan surgical resection carefully.     

Splenectomy reduces packed red cell transfusion requirement in children with sickle cell disease

Purpose

The purpose of the study was to measure the effect of splenectomy on packed-cell transfusion requirement in children with sickle cell disease.

Methods

Thirty-seven sickle cell children who underwent splenectomies between January 2000 and May 2006 at a children's hospital were reviewed. Data were collected 6 months preoperatively to 12 months postsplenectomy. Paired t test, analysis of variance, and multivariable regression analyses were performed.

Results

Of 37 children with median age 11 years (range, 2-18 years), 34 (21 males) had data that allowed analyses. Twenty-six had Hgb-SS, 5 had Hgb-SC, and 3 had Hgb S-Thal. Laparoscopic splenectomy was attempted in 36 and completed successfully in 34 (94% success). The number of units transfused decreased by 38% for 0 to 6 months and by 45% for 6 to 12 months postsplenectomy. Postoperatively, hematocrit levels increased and reticulocytes concurrently decreased with a reduction in transfusion clinic visits. The decrease in transfusion was not influenced by spleen weight, age, or hemoglobin type. Two children had acute chest syndrome (6%), and 1 had severe pneumonia (3%).

Conclusion

Laparoscopic splenectomy can be successfully completed in sickle cell children. Splenectomy significantly reduces the packed red cell transfusion requirement and frequency of clinic visits, in sickle cell children for at least 12 months postoperatively.     

Thoracoscopic evacuation of retained posttraumatic hemothorax

Background

Residual posttraumatic hemothoraces occur in 1% to 20% of patients managed with tube thoracostomy. Video-assisted thoracoscopic surgery (VATS) has emerged as an alternative to thoracotomy to evacuate these retained collections. This report reviews a recent trauma unit experience with thoracoscopic evacuation of hemothoraces.

Methods

The records of all trauma patients undergoing surgical intervention for retained hemothoraces over the 30-month period January 2001 to June 2003 were reviewed.

Results

The study included 46 patients. All sustained penetrating injuries, 40 with stab and 6 with gunshot wounds. Twenty-two, 17, and 7 patients each had one, two and three attempts at drainage with tube thoracostomy, respectively. In 37 patients (80%), retained infected/uninfected pleural fluid was successfully evacuated thoracoscopically. VATS failed in 9 (20%) patients and the procedure was converted to open thoracotomy. Dense adhesions were present in all 9 of these patients. The mean time interval between injury and thoracoscopy and thoracotomy, was 13.3 days (range 3-46 days) and 14.5 days (range 11-24 days), respectively. The mean volume of pleural fluid evacuated thoracoscopically was 650 mL. The failure of VATS evacuation correlated with the empyema rate. The median postoperative stay was 5 days for both groups.

Conclusions

Video-assisted thoracoscopic surgery is an accurate, safe, and reliable operative therapy for retained posttraumatic pleural collections, even in patients presenting later than the conventionally accepted 3- to 5-day window from the time of injury.     

Biliary complications after orthotopic liver transplantation from donors after cardiac death: broad spectrum of disease

Background

Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes.

Materials and Methods

We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months).

Results

Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%).

Conclusion

Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.     

Perinatal management of gastroschisis: analysis of a newly established clinical pathway

Purpose

The authors developed a clinical pathway for optimal management after antenatal diagnosis of gastroschisis. This is the outcomes analysis of our first 30 consecutive patients.

Method

Antenatal counseling was provided for all families with in-utero diagnosis of gastroschisis. Bowel dilatation, thickness, motility, amniotic fluid volume, and fetal development were followed by ultrasonography every 4 weeks. Babies were delivered by cesarean section between 36 and 38 weeks gestation if the lungs were mature or earlier for bowel complications. Gastroschisis repair was scheduled 90 minutes after birth. Primary repair was attempted in all through the abdominal wall defect without an additional incision, resulting in an umbilicus with no abdominal scar.

Results

Primary repair was achieved in 83%. Babies needed assisted ventilation for 3 days, reached full feeds by 19 days, and were discharged by 24 days (all medians). There were 3 (10%) deaths, all after staged repair.

Conclusions

Our new protocol of both scheduled elective cesarean section and early gastroschisis repair resulted in a higher proportion of primary repair, shorter duration of mechanical ventilation, earlier full feeds, and shorter length of stay. There was no increase in mortality or morbidity. The primary-repair babies had no mortality and had excellent cosmesis.     

Retrieval of immature oocytes from unstimulated ovaries followed by in vitro maturation and vitrification: A novel strategy of fertility preservation for breast cancer patients

Background

We report a novel fertility preservation strategy that may be useful for young breast cancer patients who present with time constraints or concerns about the effect of ovarian stimulation.

Methods

The protocol involves retrieval of immature oocyte from unstimulated ovaries followed by in vitro maturation (IVM), and vitrification of oocytes or embryos.

Results

Thirty-eight patients (age 24-45 years) underwent vitrification of oocytes (n = 18) or embryos (n = 20). The mean ages were 33.1 ± 5.0 years and 34.7 ± 4.8 years, respectively. The mean days required to complete the egg collection was 13 days. The median numbers of vitrified oocytes and embryos per retrieval were 7 (range 1-22) and 4 (range 1-13), respectively.

Conclusions

The strategy of immature oocyte retrieval without ovarian stimulation followed by IVM and oocyte or embryo vitrification, which does not increase the serum estradiol level and delay cancer treatment, represents an attractive option of fertility preservation for many breast cancer patients.     

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl

Study Objective

To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose.

Design

Randomized, double-blinded study.

Setting

Labor suite of a tertiary care hospital.

Patients

60 ASA physical status 1 and 2, laboring, nulliparous women.

Interventions

All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 μg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 μg/mL at 10 mL/hr (epinephrine group).

Measurements

Time to re-dose, pain scores, and side effects were recorded.

Main Results

The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04).

Conclusions

The administration of 0.625 mg/mL bupivacaine with epinephrine 5 μg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.     

Early enteral nutrition can be successfully implemented in trauma patients with an “open abdomen”

Background

The presence of an “open abdomen” after a trauma laparotomy can complicate the nutritional management of injured patients.

Methods

The medical records of patients admitted to an American College of Surgeons-verified level 1 trauma center were evaluated. The timing of nutritional support was noted. The method to obtain abdominal closure was also noted.

Results

Twenty-three patients were included in the study. Enteral nutrition was successfully initiated in 52% of patients before fascial closure. Enteral nutrition was initiated 3.8 days after the initial laparotomy in these patients. All patients successfully achieved fascial and skin closure, obviating the need for delayed hernia repair or skin grafting.

Conclusions

Enteral nutrition can be successfully initiated in patients with “open abdomens.” In our series, early enteral nutrition did not alter our ability to ultimately obtain fascial and skin closure.     

Contemporary outcomes of open thoracic aortic surgery in a veteran population: do risk models exaggerate mortality?

Background

We evaluated contemporary outcomes of open thoracic aortic surgery at a Veterans Affairs (VA) medical center affiliated with a major academic aortic program and examined the predictive value of 2 established cardiac risk models.

Methods

We retrospectively reviewed all open thoracic aortic operations performed between April 1998 and April 2008 (n = 100). Both the EuroSCORE and the VA Continuous Improvement in Cardiac Surgery Program (CICSP) scores were evaluated.

Results

Procedures included ascending aortic repair (n = 74, 15 with arch repair), descending thoracic repair (n = 11, 1 with arch repair), and thoracoabdominal aortic repair (n = 15). Emergency surgery was necessary in 15 cases, and 19 procedures were reoperations. The patients' logistic EuroSCORE and the CICSP scores were similar (18.7% and 18.2%, respectively), but both scores significantly exceeded the observed operative mortality rate (8.0%, P = .008).

Conclusions

Good outcomes can be achieved when thoracic aortic surgery is performed at an experienced VA center. The cardiac risk models we examined overpredicted operative mortality.     

Current management of adolescent pilonidal disease

Background

Controversy persists regarding the optimal management for adolescent pilonidal disease. We reviewed the outcome of wide local excision (WLE) vs unroofing and marsupialization (UM) for pilonidal disease.

Methods

A retrospective review 2002 to 2007 of adolescents undergoing surgical treatment of pilonidal disease was performed. Data were analyzed using Student's t test.

Results

Twenty-six patients were treated for pilonidal disease during this period. Average age was 16.7 years (range, 14-19 years) with 50% males. Nine patients underwent WLE and 17 had UM. Before initial evaluation, 44% of patients in the WLE group had drainage of acute abscess compared to 59% in the UM group (P > .05). Postoperative complications in the WLE group (78%) were significantly higher compared to the UM group (0%). Median time for final healing was significantly higher in the WLE group (32 weeks) compared to the UM group (6 weeks). The reoperative rate was also significantly higher in the WLE group (56%) compared to the UM group (0%). No patient had recurrent disease after complete healing in either group.

Conclusion

Unroofing and marsupialization for primary pilonidal disease has a shorter time to heal and carries a lower complication and reoperative rate compared to WLE.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Efficacy of prophylactic epicardial pacing leads in children and young adults

Background

Epicardial pacemakers are often required in children and young adults who cannot undergo a transvenous system because of patient size, vascular barriers, or significant residual intracardiac shunts. Prophylactic epicardial pacing leads, placed at the time of concomitant congenital heart surgery, may reduce a late thoracotomy or sternotomy. The efficacy of prophylactic epicardial leads in the pediatric population is unknown.

Methods

A retrospective review of the cardiovascular surgery and pacemaker databases at The Children's Hospital of Philadelphia identified all patients less than or equal to 21 years of age, who underwent placement of an epicardial pacing lead between January 1, 1990 and December 31, 2002. Prophylactic epicardial pacing leads placed at the time of a concomitant congenital heart procedure were compared to standard epicardial leads that were connected to a simultaneous programable generator. Pacing and sensing threshold data were obtained in prophylactic epicardial leads at the time of lead retrieval and 6 month follow-up and compared to standard epicardial pacing leads.

Results

Twenty-two (13 ventricular, 9 atrial) prophylactic epicardial pacing leads were retrieved in 13 patients at a median of 252 days (7 days to 3.98 years) from the time of initial implant and compared to 256 (164 ventricular, 92 atrial) standard epicardial leads placed in 142 patients. Nineteen (86%) prophylactic epicardial leads had acceptable pacing and sensing thresholds at lead retrieval. Only 1 patient with atrial and ventricular leads had poor pacing and sensing at retrieval and required a redo-sternotomy for placement of new atrial and ventricular epicardial pacing leads. For the remaining atrial (n = 7) and ventricular (n = 12) prophylactic epicardial leads, there was no significant difference in pacing (atrial, 1.59 ± 1.1 μJ; ventricular, 1.98 ± 1.9 μJ) or sensing (atrial, 3.6 ± 1.8 mV; ventricular, 13.8 ± 4.4 mV) compared to standard pacing (atrial, 2.1 ± 1.8 μJ; ventricular, 1.9 ± 3.4 μJ) and sensing (atrial, 3.3 ± 1.7 mV; ventricular, 11.3 ± 5.3 mV) epicardial leads. Six-month follow-up pacing and sensing thresholds were not significantly different between the prophylactic and standard epicardial pacing leads.

Conclusions

Prophylactic epicardial pacing leads can be successfully placed and retrieved in a subset of children and young adults who will likely require pacing at a later date. Prophylactic leads have comparable pacing and sensing qualities at lead retrieval and short-term follow-up compared to standard epicardial leads. Consideration for prophylactic epicardial pacing leads will likely reduce the need for a late thoracotomy or sternotomy.     

Outcome in Children Bridged and Nonbridged to Cardiac Transplantation

Background

Heart transplantation (HTx) in children with end-stage heart disease has become an accepted treatment option.

Objective

To evaluate our results of pediatric cardiac transplantation with vs without bridge methods.

Patients and Methods

The study included 31 patients (34 transplantations) younger than 18 years who underwent orthotopic HTx between March 1995 and December 2008. Ten patients were girls, and 21 were boys. Preoperative diagnoses included cardiomyopathy (n = 20), congenital heart disease (n = 7), hypertrophic cardiomyopathy (n = 2), restrictive cardiomyopathy (n = 1), and ischemic cardiomyopathy (n = 1). Mean (SD) ischemia time was 185 (72) minutes. Thirty-day mortality was 6%, and was due to primary graft failure (n = 2). Overall follow-up was 4.36 (3.93) years. Eleven patients underwent bridge techniques before HTx, and 11 patients required perioperative extracorporeal membrane oxygenation or ventricular assist device support.

Results

In the group that received extracorporeal membrane oxygenation, 8 patients (73%) were successfully weaned and discharged with excellent functional class. There were no differences in operative mortality, functional class, survival, rejection, and infection rates between the bridged and nonbridged groups. Overall actuarial 1- and 5-year survival rates were 93% and 83%, respectively. All survivors had good functional class.

Conclusion

Our findings demonstrate satisfactory medium-term outcome of HTx in selected pediatric patients with end-stage heart disease. Using bridge methods in children at high risk can increase the opportunity to receive a donor heart. These bridge methods achieve similar postoperative outcomes.     

Altered chemokine response in an animal model of multiple organ dysfunction syndrome induced by zymosan

Purpose

The aim of this study was to determine the monocyte chemoattractant protein-1 (MCP-1) response over time in an animal model of multiple organ dysfunction syndrome (MODS).

Methods

On day 0, rats were randomized to receive an intraperitoneal injection of zymosan at a dose of 1 mg/g of body weight (n = 36) or vehicle (n = 9). Serum, peritoneal lavage (PL) fluid, and bronchoalveolar lavage (BAL) fluid were collected from 3 rats in the control group and 6 to 7 rats in the zymosan group at days 1, 5, and 12. Monocyte chemoattractant protein-1 concentrations were determined by enzyme-linked immunosorbent assay.

Results

The authors observed a 47% mortality in the zymosan-treated rats. Monocyte chemoattractant protein-1 levels were unchanged in the serum, PL, and BAL of control animals. Both serum and PL MCP-1 were significantly higher in zymosan-treated rats on days 1 (P < .01) and 5 (P < .05) when compared with controls. By day 12, no difference between the 2 groups was observed. No significant difference was noted in BAL MCP-1.

Conclusions

Chemokines are increased systemically and locally during MODS. The fact that MCP-1 is significantly higher early in the course of MODS may suggest that this chemokine is important in the early inflammatory changes that lead to MODS later in the course of this illness.     

Conjoined twins--past, present, and future

Background/Purpose

Conjoined twins are rare and complex anomalies of the newborn. They require a highly experienced team and a center equipped to deal with such challenging anatomy.

Method

A review of 31 sets of conjoined twins was managed by one team over a 15-year period. The spectrum of the anomalies, management strategies, and outcomes will be analyzed with future recommendations.

Results

Ten sets of complete conjoined twins and two sets of parasitic conjoined twins were successfully separated. Tissue expanders and prosthetic meshes were not required. A separation of one set of craniopagus parasiticus conjoined twins was attempted, but abandoned owing to major vascular and brain sharing. The remaining 18 sets were not separable owing to major cardiac anomalies and/or sharing, and all died within several weeks of birth.

Conclusion

Careful planning, a multidisciplinary approach, rehearsal, and experience are important factors in dealing with conjoined twins. Tissue expanders and prosthetic meshes are not required in most cases. Selective abortion or fetal intervention may play a role in the future.     

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device

Purpose

The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele.

Methods

The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation.

Results

The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia.

Conclusions

The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.     

Pelvic osteomyelitis: a diagnostic challenge in children

Background

Acute hematogenous osteomyelitis (AHOM) in children usually occurs in tubular bones. Acute hematogenous osteomyelitis of the pelvis is rare and is often not recognized primarily.

Methods

To review the experience with pelvic AHOM at our institution, we analyzed records from children diagnosed with pelvic AHOM (1984-2003) and compared with those reported in the literature.

Results

Among 220 children with AHOM (median age, 6.4 years), those 19 (9%) with pelvic AHOM were significantly older (median age, 9.0 years; range, 0.04-15.6). All children presented with limping or refused to walk. Twelve of 19 patients were febrile, 16 of 18 had elevated C-reactive protein (>20 mg/L), and 6 of 19 had leukocytes greater than 12 G/L. Staphylococcus aureus was isolated from blood or bone aspirates in 9 of 17 patients, and Streptococcus pneumoniae was isolated in 1. Scintigraphy was diagnostic in 15 of 15 children, and magnetic resonance imaging in 7 of 7 children. The mean time between initial symptoms and diagnosis was 3 days (range, 1-8 days). Infection resolved completely in all children after antibiotic therapy.

Conclusion

Pelvic AHOM should be considered in children with limping and pain referred to the hip, thigh, or abdomen. Diagnosis by scintigraphy or magnetic resonance imaging followed by local puncture and microbiological workup allows for specific antibiotic treatment and results in an excellent outcome of pelvic AHOM.     

Surgical treatment of biliary tract complications after liver transplantation

Objective

Biliary strictures are the most common biliary tract complication after liver transplantation. There are scarce data on the results of hepaticojejunostomy (HJ) in the management of biliary complications after orthotopic liver transplantation (OLT). Thus, the role of surgery in this setting remains to be established. The aim of this study was to evaluate the results of surgical treatment of patients with biliary complications at our institution.

Patients and Methods

We reviewed 1000 consecutive liver transplantations performed at our institution from 1984 to 2007. We used a prospectively recorded database to identify patients who underwent HJ to treat any biliary tract complication.

Results

Overall, 62 patients (6.2%) underwent HJ, 40 for an anastomotic and 7 for a non-anastomotic stricture as well as 15 for biliary leaks. Postoperative morbidity was 16%, and postoperative mortality 1.6%. There were 7 cases of anastomotic stenosis (11.3%). Four patients (5%) required retransplantation.

Conclusions

HJ is a safe procedure to manage biliary complications after OLT. It may be the first treatment choice especially for cases with anastomotic strictures.