Staged repair of giant omphalocele in the neonatal period

Background/Purpose

The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period.

Methods

Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range.

Results

Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months).

Conclusions

Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.     

Development and evaluation of an instrument to assess social difficulties in routine oncology practice

Purpose: To develop and preliminarily evaluate a Social Difficulties Inventory (SDI) for use in oncology practice. Methods: Item generation from patients (n=96), staff (n=49) and the literature. Questions constructed and pre-tested (n=42) resulting in a 22-item questionnaire. Psychometric evaluation (n=271) assessed frequency of endorsement, factor structure, summated scales and construct validity followed by randomisation to criterion validity or test-retest arms. Results: Items met preset frequency of endorsement criteria. Factor analysis revealed a four-factor structure, three clearly definable, (1) Physical ability, (2) Providing for the family and (3) Contact with others, explaining 45.8% variance. Summated scales developed from these demonstrated good reliability (Cronbachs alpha > 0.7) and were used to test and confirmed construct validity. Several comparators from the Life Events and Difficulties Schedule (LEDS) and CAncer Rehabilitation Evaluation System Short Form (CARES-SF) tested criterion validity and majority agreements were moderate to good. Test–retest reliability was good with most kappa values > 0.6. One item was eliminated resulting in a 21-item questionnaire. Conclusion: The SDI is relevant and easy to understand. Initial psychometric evaluation was encouraging. Ongoing work to evaluate the clinical meaning and utility of the instrument and to examine the relationships between SDI scores and clinical outcomes will provide guidance about its usefulness as an assessment tool in routine oncology practice.Presented in part at the British Cancer Research Meeting (poster presentation) 2001 and at the World Congress of Psycho-Oncology (poster presentation) 2003.     

Retrospective comparison of open versus laparoscopic pyloromyotomy

BACKGROUND: Laparoscopic pyloromyotomy is gaining popularity in the management of pyloric stenosis. However, there is no unequivocal evidence in favour of the laparoscopic over the open approach. This paper reports an experience with laparoscopic pyloromyotomy and an attempt to identify any benefit over the open procedure. METHODS: This was a retrospective review of all 87 pyloromyotomies performed at this institution for pyloric stenosis over the 39 months since the first laparoscopic pyloromyotomy was performed. RESULTS: Data for 39 infants who underwent laparoscopic pyloromyotomy were compared with those for 38 infants who underwent pyloromyotomy via a periumbilical incision. Patient demographics were similar between the two groups. The duration of operation was longer for laparoscopic pyloromyotomy than for the open procedure (median 50 versus 30 min; P = 0.001). There were no differences in recovery time, postoperative length of hospital stay, complication rates and postoperative analgesia requirements between the two groups. CONCLUSION: Laparoscopic pyloromyotomy has been incorporated successfully into the authors' standard working practice. Complication rates recovery times were similar to those achievable with the open procedure. There was no clear benefit of one approach over the other.     

Toxicity and Cerebrospinal Fluid Levels of Carboplatin Chronically Infused into the Brainstem of a Primate

PURPOSE: Carboplatin was infused into the brainstem of cynomolgus monkeys to investigate neurotoxicity and systemic exposures following chronic local delivery. METHODS: Infusions at 0.42 microl/h were intended to deliver 0.025 (n = 2), 0.075 (n = 3), 0.25 (n = 5), and 0.75 (n = 3) mg/kg by day 30. Laboratory tests, radiographic measurements, and clinical observations were used to monitor toxicity. Blood and cerebrospinal fluid (CSF) were sampled for platinum. RESULTS: Lethargy and ataxia were observed after week 4 in the monkeys given 0.075 mg/kg, and week 2 in the monkeys given 0.25 mg/kg when the infused doses were approximately 250 and 400 microg, respectively. Rapidly progressive neurotoxicity with the 0.75 mg/kg dose required termination of the infusions at days 4-10. Hematology and chemistry values were unremarkable in all groups. Blood levels of platinum remained undetectable in 0.025 and 0.075 mg/kg dose groups. Levels in the 0.25 mg/kg group were 3.1 +/- 0.6 microg/l at 2 weeks and 5.2 +/- 0.8 microg/l at 1 month. The CSF platinum levels varied. Animals in the 0.25 mg/kg group had higher CSF levels at 2 weeks (avg. 65 microg/l, range 36-89) compared to their 1 month value (avg. 60 microg/l, range 7-170), despite the constant infusion. CONCLUSION: Carboplatin can be chronically infused into monkey brainstems. Neurotoxicity is the predominant side effect and is dose-dependent. Pharmacokinetics of local and systemic delivery are different for carboplatin. Further studies are needed to monitor toxicity at higher flow rates and to investigate drug binding to abnormal central nervous system (CNS) tissues.     

Carbon dioxide elimination during laparoscopy in children is age dependent

The absorption of carbon dioxide (CO₂) used for positive pressure pneumoperitoneum may lead to an increased CO₂ load. CO₂ elimination during laparoscopy has not been investigated previously in paediatrics. The aim of this study was to characterise the pattern of CO₂ elimination during laparoscopic surgery in infants and children. Methods: Twenty children undergoing laparoscopy and 19 children undergoing laparotomy for elective abdominal operations were studied. Pneumoperitoneum was achieved using insufflation of unheated CO₂. CO₂ elimination (metabolically produced + absorbed; milliliters per kilogram per minute) was measured minute by minute during the operation by indirect calorimetry. End-tidal CO₂ (kPa) was recorded every 10 minutes. The above variables were assessed before CO₂ insufflation, during pneumoperitoneum, and after desufflation. Results: Before insufflation, CO₂ elimination was 4.6 [plusmn] 0.3 ml/kg/min and increased after 15 minutes of pneumoperitoneum to 5.2 [plusmn] 0.3 (P [lt ] .001). Post desufflation, CO₂ elimination decreased toward preinsufflation values, but did not return to baseline by the end of operation (5.8 [plusmn] 0.3; P [lt ] .001). End-tidal CO₂ was 4.7 [plusmn] 0.2 preinsufflation, peaked at 1 hour (5.3 [plusmn] 0.2; P [lt ] .001) and subsequently decreased in response to ventilatory adjustments. The total amount of CO₂ insufflated was positively correlated with patient age (r² = 0.27; P [lt ] .01). CO₂ elimination was age related, as indicated by multilevel model analysis and by negative correlations between maximum increase in CO₂ elimination and both age (r² = 0.27; P [lt ] .01) and weight (r² = 0.29; P [lt ] .01). These data suggest that the younger or smaller the child, the larger the increase in CO₂ elimination. Seven patients (35%) responded to desufflation with a sharp transient increase in CO₂ elimination, which did not appear to be related to patient age, length of pneumoperitoneum, abdominal pressure, or type of operation. Conclusions: During pneumoperitoneum, younger children absorb proportionately more CO₂ than older individuals. The short-lived increase in CO₂ elimination postdesufflation may be related to an increase in venous return from the lower limbs after release of the abdominal pressure. These findings suggest that small children warrant close monitoring during laparoscopy and during the immediate postoperative period. J Pediatr Surg 38:105-110.     

Isoflavone intake in four different European countries: the VENUS approach

The aim of this study was to identify the level of isoflavone intake (total isoflavones, daidzein and genistein) in four European countries: Ireland, Italy, The Netherlands and the UK. For this purpose national food composition databases of isoflavone content were created in a comparable way, using the Vegetal Estrogens in Nutrition and the Skeleton (VENUS) analytical database as a common basis, and appropriate food consumption data were selected. The isoflavone intake in Ireland, Italy, The Netherlands and the UK is on average less than 1 mg/d. Small groups of consumers of soya foods could be identified in Ireland, The Netherlands and the UK. The estimated intake levels are low compared with those found in typical Asian diets (approximately 20-100 mg/d) and also low compared with levels where physiological effects are expected (60-100 mg/d). The results (including a subgroup analysis of soya product consumers) showed that such levels are difficult to achieve with the European diets studied here.     

Day case laparoscopic cholecystectomy is feasible

Background

Laparoscopic cholecystectomy is the operation of choice for cholelithiasis.

Aims

The aims of our study were to assess the feasibility of day case laparoscopic cholecystectomy (DCLC) in selected patients.

Methods

DCLC was introduced in this unit in July 1999, The first 50 patients were prospectively evaluated up to February 2001.

Results

All patients were under 55 years of age with an ASA grade of I (n=48) or II (n=2). The mean age was 41.1 years (range 20–55 years) and the male:female ratio was 1:6. All patients had a standard anaesthetic protocol. Patients were discharged 10 to 12 hours postoperatively with a pro forma, which was reviewed at one week in the clinic, The conversion rate was 2%. Three required overnight admission due to excessive nausea, hypertension and for an unforeseen psychosocial problem. Ninety per cent of patients were suitable for same day discharge. No patient required subsequent readmission.

Conclusion

DCLC is feasible and safe in carefully selected patients and has the advantages of convenience and cost-effectiveness.     

Prolonged QT interval and cardiac arrhythmias in two neonates: sudden infant death syndrome in one case

Two neonates with arrhythmias and the long QT syndrome are described. The arrhythmias were detected in utero and both infants were apparently well after birth. The first infant, although well, had a bradycardia for the first 9 days of life. A normal heart rate was documented at 10 days but a prolonged QT interval was not appreciated on the ECG. He was discharged from hospital but died suddenly and unexpectedly 3 days later. A post-mortem examination failed to find a cause for his death which therefore fell into the category of the sudden infant death syndrome (SIDS). A retrospective analysis of the perinatal electrocardiogram showed a probable junctional rhythm with 2:1 conduction to the ventricle; the QT interval was prolonged at 0.52 seconds (QTC = 0.63). The second infant had a QT interval of 0.52 seconds (QTC = 0.54) and frequent ventricular premature beats on a 24-hour electrocardiogram. She was treated with propranolol and remains well 2 years later. Sudden infant death has often been described in the siblings of children with the long QT syndrome and one other report described a case of SIDS which was said to have had a prolonged QT interval on the perinatal ECG. This report, however, provides unquestionable evidence, in one case, of an association between the long QT syndrome and SIDS.