Extrahepatic portal hypertension in children

In children the principal cause of extrahepatic portal hypertension is a “cavernomatous transformation” of the portal vein. In 54 children seen over a 20-yr period, hemorrhage was by far the most common presenting symptom, occurring in 30 patients. Occasionally these children presented with a symptomless splenomegaly. Liver function studies were always normal. The patients were classified into four groups, depending on the particular primary surgical treatment given. One-third of patients received no surgical treatment and all are well. Of the patients who have had a surgical procedure, postoperative bleeding has been frequent and further surgery has often been necessary. There have been seven deaths. Operation is not recommended in the child under 4 yr or during acute bleeding episodes. For recurrent life-threatening hemorrhage, a porto-systemic shunt is indicated.     

Effects of PEEP on cardiovascular dynamics after open-heart surgery: a new postoperative monitoring technique.

The circulatory effects of incremental increases in positive end-expiratory pressure ventilation (PEEP) were assessed on 11 occasions in post-operative cardiac surgical patients by phasic aortic blood flow measurements and high-fidelity pressure recordings from which flow and pressure-flow derivatives of cardiac performance were calculated. At 15 cm H2O PEEP, mean arterial blood pressure was decreased by 10%, stroke volume and cardiac output by 15%, and peak left ventricular power by 21%. Although these indices promptly returned to control levels when PEEP was discontinued, levels of PEEP above 10 cm H2O should be used with caution for this group of patients.     

Establishment of a viable homograft cardiac valve bank: a rapid method of determining homograft viability.

A method for determining the viability of homograft valves has been developed based on sequential measurements of glucose and pH levels of the culture medium in which cardiac valves have been maintained for short periods at 37 degrees C. Viable valves, as determined by tissue culture, showed a characteristic pattern of glucose utilization and pH reduction that was absent in nonviable valves. Upon explantation of valve leaflet fragments into tissue culture, only fragments from valves that metabolized glucose produced viable fibroblast cultures. The method reported here is rapid, requires no specialized equipment, is nondestructive, and can directly determine the viability of the valve homograft within 24 to 48 hours.     

A monitor for the continuous assessment of left ventricular performance after open-heart operations.

A cardiac monitoring system has been developed that incorporated phasic aortic blood flow measurement by an extractable electromagnetic flow probe and high-fidelity arterial blood pressure recordings. Cardiac output, stroke volume, and peak aortic blood flow are measured continuously; using logarithmic amplifiers, the pressure-flow derivatives of left ventricular function, such as cardiac power and stroke work, are obtained beat by beat. This monitor is used to follow the postoperative course of patients undergoing cardiac operations and to evaluate the hemodynamic effect of therapeutic agents.     

Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch

Banked blood transfusion, with its attendant hazards, may be avoided in certain instances. A search for an acceptable plasma substitute was made. A randomized prospective trial of hydroxyethyl starch (HES) versus plasma for postoperative volume replacement is described. Ninety patients undergoing operations for coronary artery disease were studied over a six-month period. Ten received banked blood in the immediate postoperative period and were excluded from the study. The remaining 80 were randomized into two groups. Group 1 received plasma, and Group 2 received HES. All patients initially had autologous blood transfusion, and in 7 patients this sufficed; these patients were excluded from the study except for regression analysis. Postoperative blood loss and urine output did not differ between groups, but Group 2 patients required significantly more volume replacement (p less than 0.02). In a total of 27 patients drawn from both groups, coagulation factors and colloid osmotic pressure were investigated. There were no significant differences in fibrinogen titer and prothrombin time between groups, but return to normal values was significantly delayed in the HES group (p less than 0.01). Activated clotting time and partial thromboplastin time were unaffected. Colloid osmotic pressure was significantly higher at one week in the HES group (p less than 0.001) and was correlated with the volume of HES given (r = 0.525; p less than 0.01). There were no untoward effects attributable to HES. It is concluded that HES is a safe, cheap, and effective plasma substitute for volume replacement following cardiac surgical procedures.     

Secondary scalp and forehead reconstruction using free flaps

Four free flap transfers for secondary scalp and forehead reconstruction in burned children are reported. The method proved useful in solving these unusual and difficult reconstructive problems.     

Mustard procedure after Baffes operation.

Patients in whom Baffes' procedure has been done for palliative treatment of transposition of the great arteries may develop symptom recurrence later in life that deserves further treatment. A modified Mustard procedure is suitable for this purpose; the main difficulty in performing a formal Mustard operation is the proximity of the superior vena cava and of the inferior vena caval graft openings that enable the left pulmonary veins to drain without obstruction into the new atrium. This report deals with a 15-year-old patient in whom a modified Mustard technique was employed as a palliative method.     

The management of empyema thoracis by thoracoscopy and irrigation

A technique of irrigation for the management of empyema is described. Initial thoracoscopy under general anesthesia enabled full debridement and division of loculi within the empyema cavity under direct vision. Irrigation with two tubes was instituted until three consecutive cultures of irrigation fluid became sterile; then the chest drains were removed. The results in 12 patients are presented. Using this method, irrigation was required for an average of 14 days and chest drains were removed after an average of 20 days. Patients remained in the hospital for an average of 4.8 weeks. Tuberculous empyema was not found to be a contraindication to the irrigation technique.     

Acid-base balance and blood gases in prognosis and therapy of congenital diaphragmatic hernia

The acid-base balance and gas-exchange mechanisms and their correlation with the pathologic findings in the lungs of children with diaphragmatic hernia determines prognostic and therapeutic criteria.The existence of a severe respiratory acidosis that does not improve after positive-pressure mechanical ventilation and the existence of a high degree of arteriovenous shunting are bad prognostic signs. The initial laboratory data and their modification after intensive mechanical ventilation are useful in establishing prognosis and in guiding therapy.     

Prosepctive analysis of heart biopsies in coronary artery surgery.

In a prospective analysis of 36 biopsies from human hearts performed at the time of elective coronary operation, several morphological changes were identified in the myocardium. Some of these changes (fibrosis, vacuolation, edema, and amyloid deposition) are of clinical signficance and may affect the long-term prognosis for patients undergoing revascularization procedures. It appears, therefore, that knowledge of the morphological state of the myocardium at the time of operation can prove useful in elucidating further the long-term effects of coronary artery bypass on the left ventricular myocardium.     

Elimination of venting in coronary artery surgery.

The present study is a prospective analysis of 78 consecutive patients undergoing coronary operation without venting of the left ventricle. Results indicate that with cardioplegic arrest left ventricular distention does not occur when the venous lines are positioned in the right atrium. The technique described here has simplified the pump setup, shortened the operative time, and eliminated the potential hazards associated with venting the left ventricle.     

Mediastinal infection after cardiac surgery

Mediastinitis is an uncommon complication after cardiac surgery; however, its associated morbidity and mortality demand early recognition and emergency therapy. This review is intended to emphasize certain features of the incidence, pathogenesis, and bacteriology of this complication in patients undergoing cardiopulmonary bypass through a median sternotomy. The diagnosis and treatment of mediastinitis after cardiac surgical procedures, as well as methods of prevention, are also reviewed.     

Myoelectrical activity of the canine stomach and duodenum after gastric resection

Distal gastric resection has long-lasting effects on the basal electrical rhythm of the canine stomach and duodenum. After Billroth I resection, duodenal fast activity is no longer controlled by the gastric basal electrical rhythm and is excessive and uncoordinated. Segmental resection of the stomach is followed by a high incidence of retrograde conduction of the basal electrical rhythm of the stomach and duodenum. Pylorus-preserving gastrectomy reduces this retrograde activity to a minimum.