A system for the analysis of seat support surfaces using surface shape control and simultaneous measurement of applied pressures

Chronic aspiration in the neurologically impaired child is associated with significant medical and social complications. Traditional surgical management has often relied on tracheotomy. This may well fail to control aspiration. The purpose of this retrospective study was to determine which neurologically impaired children would benefit from a laryngotracheal separation (LTS), as opposed to tracheotomy, as the primary surgical procedure to control chronic salivary aspiration. Patient selection was based on neurologic status, verbal communication ability, likelihood of neurologic recovery, and failure of previous treatments to control aspiration. Nineteen neurologically impaired children aged 8-172 months with chronic salivary aspiration underwent LTS. A total of 73.6% of these patients had prior tracheotomies, yet they continued to aspirate. Two early and three late complications were noted. No instances of fistula formation were noted. There were no deaths related to complications of the surgery or persistent aspiration. Follow-up 1-62 months after surgery demonstrated that complete control of the aspiration was achieved in all of these children. Two of the children who had achieved verbal communication prior to the procedure lost this ability. Improved general health and ability to resume oral intake was noted in all patients. This, combined with a decrease in the need of frequent suctioning, was felt by the families of these children to be a major improvement in the quality of life. Laryngotracheal separation appears to be a simple and effective means of controlling chronic aspiration. It should be considered as a primary treatment of aspiration in the properly selected child with neurologic disease.     

Retrograde fibreoptic intubation in a child with Nager's syndrome

PURPOSE: The authors describe a retrograde fibreoptic technique for tracheal intubation in a micrognathic child with a tracheo-cutaneous fistula. CLINICAL FEATURES: A four-year-old child with Nager's syndrome presented for surgical closure of a tracheocutaneous fistula. A tracheostomy tube had been placed in the neonatal period for management of upper airway obstruction due to severe micrognathia. At 2 1/2 yr of age, after a successful mandibular advancement procedure, the tracheostomy was removed and the child allowed to breathe through the natural airway. Preoperative physical examination revealed an uncooperative child, unable to open her mouth due to limited temporo-mandibular motion. The child was first anaesthetized with ketamine, 70 mg im, then halothane by mask. The authors were unable to open the child's mouth sufficiently to allow rigid laryngoscopy. Attempts at oral and nasal fibreoptic intubation were unsuccessful. Ultimately, the authors were able to intubate nasally by passing an ultrathin Olympus LF-P laryngoscope under direct vision through the tracheocutaneous fistula in a cephalad direction, through the larynx and nasopharynx, then out the nares. An endotracheal tube was then advanced over the fibreoptic scope and positioned distal to the tracheocutaneous fistula. The surgical procedure was successfully accomplished and the trachea was extubated postoperatively without difficulty. CONCLUSION: Retrograde fibreoptic intubation may be an option for airway management of a select group of children who cannot be intubated by traditional techniques.     

The dietitian''s role in developing and implementing the first federal obesity guidelines

OBJECTIVE: To determine possible indications for tracheotomy in the burned child based on bronchoscopic and laryngoscopic findings. DESIGN AND SETTING: A retrospective case study of all patients admitted to a tertiary children's burn center. PARTICIPANTS: All children admitted with burn inhalation injury between 1990 and 1995 (n = 211). INTERVENTION: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tracheotomy tubes placed emergently. MAIN OUTCOME MEASURES: Observations during laryngoscopy and bronchoscopy included erythema, edema, carbonaceous material, ulcerations, and bronchial mucous casts. The supraglottis, glottis, and subglottis were analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, such as glottic webs, subglottic stenosis, and tracheomalacia, were noted. RESULTS: Indications for tracheotomy included 6 for airway obstruction, 6 for prolonged intubation, 6 for pulmonary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by bronchoscopy and laryngoscopy, 17 of 19 children had significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. CONCLUSIONS: Tracheotomy is indicated in the burned child when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence of immediate tracheotomies (26%). There was no evidence of clinically significant infection attributable to tracheotomy. The number of airway complications due to tracheotomy was no higher than from endotracheal intubation.     

Percutaneous dilatational cricothyroidotomy: outcome with 44 consecutive patients

OBJECTIVE: To assess the value of the percutaneous dilatational technique in elective cricothyroidotomy. DESIGN: Forty-four consecutive patients requiring prolonged mechanical ventilation. SETTING: The general 14-bed intensive care unit of a university hospital. INTERVENTIONS: Fourty-four percutaneous dilatational cricothyroidotomies using a multiple-dilator wire-guided procedure. MEASUREMENTS AND RESULTS: The average duration for the procedure was 11 min in 37 patients. No significant complications occurred intraoperatively except for one paratracheal cannula insertion. Postoperative complications were one case of stoma infection, three cases of transient phonatory changes, two cases of a small peristomal granuloma, and one case of persistent stoma. Of 21 decannulated patients, 16 survived to discharge. Long-term follow-up was possible in 14 surviving patients. All were asymptomatic several months after decannulation. CONCLUSIONS: Percutaneous dilatational cricothyroidotomy can be a quick, safe technique, as good as the percutaneous subcricoidal approach in ventilated, critically ill patients.     

Pediatric respiratory papillomatosis: prognostic role of viral typing and cofactors

Children with recurrent respiratory papillomatosis vary greatly in their clinical disease course. Many have mild disease with eventual remission while others present with an early aggressive airway obstructive course. This study consisted of 24 pediatric patients whose specimens underwent polymerase chain reaction analysis for cytomegalovirus (CMV), herpes simplex virus (HSV), and human papillomavirus (HPV) type. Nineteen of 24 specimens contained enough DNA for this study. None of the specimens were found to contain DNA from HPV-16, -18, -31, -33; CMV; or HSV, which contrasts with our previous findings in adults. Ten patients were infected by HPV-11 and seven of these underwent tracheotomy because of an aggressive tumorigenic clinical course. Nine patients were infected by HPV-6 alone of whom only two required a tracheotomy (P = 0.05, Fisher's Exact Test). The early airway obstructive course associated with HPV-11, however, had no bearing on achieving eventual disease remission, with decannulation achieved in eight of nine children.     

Partial cricotracheal resection with primary anastomosis in the pediatric age group

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.     

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.     

Vesicovaginal and vesicocutaneous fistulas: transurethral suture cystorrhaphy as a new closure technique

PURPOSE: We assessed the usefulness of endoscopic treatment of vesical fistulas. MATERIALS AND METHODS: Two bladder fistula patients underwent transurethral surgery in an attempt to close the fistula. RESULTS: Both patients were cured of the fistula, without undergoing an open procedure. CONCLUSIONS: Cystoscopically assisted suture closure of vesical fistulas can be a successful procedure in selected patients. Nontraditional instrumentation and technique allowed for transurethral closure of these fistulas.     

Laparoscopic cholecystectomy during pregnancy is safe for both mother and fetus

The use of laparoscopic cholecystectomy in pregnant women has been slow to gain wide acceptance for two reasons: one is the potential for mechanical problems related to the pregnant uterus and the other is fear of fetal injury resulting from instrumentation or the pneumoperitoneum. To assess the effects of laparoscopic cholecystectomy on both the mother and the unborn fetus, we reviewed our surgical experience over a 5-year period analyzing indications for the procedure along with complications and outcome. During this 5-year period, 22 patients ranging in age from 17 to 31 years underwent laparoscopic cholecystectomy during pregnancy. Gestational ages ranged from 5 to 31 weeks with two patients being in the first trimester, 16 in the second, and four in the third. The primary indications for surgical intervention were persistent nausea, vomiting, pain, and inability to eat in 17 patients, acute cholecystitis in three, and choledocholithiasis in two. In all patients a pneumoperitoneum was established by means of a closed technique starting in the right upper quadrant of the abdomen. Two of the 22 patients also underwent successful transcystic common bile duct exploration with removal of common duct stones. All 22 patients survived the surgical procedure without complications, and there were no fetal deaths or premature births related to the procedure. Based on the preceding results, it would appear that laparoscopic cholecystectomy during pregnancy is safe for both the mother and the unborn fetus. Indications for this procedure should include stringent criteria such as unrelenting biliary tract symptoms or the complications of cholelithiasis. If at all possible, when laparoscopic cholecystectomy is indicated, it should be performed either in the second trimester or early in the third.     

Complications of thoracoscopic surgery for spontaneous pneumothorax

We reviewed the cases of 122 patients with primary spontaneous pneumothorax who underwent thoracoscopic surgery at our institution between 1992 and 1995. In 9 cases, thoracotomy became necessary because of severe adhesions (3 cases), large foci (3 cases), and unrecognized foci (3 cases). Complications occurred in 17 cases: collapse in 1 patient after removal of the thoracic drain, persistent air leakage (> 7 days) in 2 patients, and recurrent pneumothorax in 14 patients. There were no significant differences between the recurrent and non-recurrent cases in age, sex location of bullae, past history of pneumothorax, operating time, intraoperative blood loss, or duration of chest tube drainage after surgery. The interval between onset and consult was significantly longer in recurrent cases than in non-recurrent cases, and the number of patients who required chest tube drainage before surgery was significantly higher in recurrent cases. Reoperation was performed in 9 cases. Bullaes that were not detected during the first surgery were found in the 7 of these cases. The recurrent cases in our study were regarded as resulting from a lack of surgical skill that may improved with increasing surgical experience. The Brinkman index was significantly higher in recurrent cases. Smoking and air-leakage before surgery may be risk factors for recurrence following thoracoscopic surgery for spontaneous pneumothorax.     

Comparison between results of ileal conduit and continent ileal bladder (VIP), after radical cystectomy

OBJECTIVES: The aim of the present study is to analyze the results achieved with the ileal bladder according to the VIP (vescica ileale Padovana) procedure. METHODS/RESULTS: We compared the results obtained in 31 patients with invasive bladder cancer who underwent radical surgery (22 underwent the ileal conduit procedure and 9 were treated by orthotopic bladder substitution) and analyzed the early complications, long-term results and physiological data of the group submitted to the VIP procedure. In the patient group submitted to the VIP procedure, there was only one case who required removal of the new bladder due to an enteroneovesical fistula. Another case developed medium serrate anular stricture of the bulbar urethra about 8 months postoperatively and was treated by endoscopic urethrotomy. The uroradiologic and urodynamic evaluations confirmed urinary tract stability integrity of renal function and good adaptation of the new reservoir. The andrological studies showed complete sexual potency in 2 of 9 patients. CONCLUSIONS: The VIP procedure appears to be a good technique, with complications no greater than those of traditional urinary diversion, and improves the quality of life of patients undergoing radical surgery for invasive bladder cancer.     

Pleurodesis with autologous blood: the results of a series of 17 cases with more than a year of follow-up

In an attempt to search for alternatives to the standard techniques of pleurodesis, we performed pleurodesis with autologous blood in 17 patients with spontaneous pneumothorax. The blood volume instilled in every procedure ranged from 50 to 60 ml. In 16 cases (94%) the early closure of the fistula was achieved. The mean follow-up period ranged from 17 and 41 months (mean: 24.2 +/- 6.3). Twelve out of the 17 patients (71%) have not had relapses of pneumothorax after pleurodesis. Tolerance was excellent, with only one complication reported: pleuritis resolved with drainage and antibiotics. Pain was not reported in any case. The were 5 relapses (29%); three were controlled with drainage and two required surgery. The obtention of chest X-rays, CT and/or pleural echography, after pleurodesis, allowed the evaluation of radiologic efficiency with that procedure. In 41% of cases suggestive findings of success were obtained; in the remaining cases no radiologic findings were observed or they were nonspecific. Nevertheless, a poor correlation was observed between radiologic findings and clinical course; therefore, these studies cannot be recommended on a regular basis. The current state of the art is commented and a consideration given to recent reports on this topic, and the advantages and drawbacks are evaluated. We conclude that future studies are necessary to properly place this procedure.     

Selecting the surgical procedure for simple and complicated esophageal achalasia in children

BACKGROUND/PURPOSE: Surgical experience in children who have achalasia is limited. Surgical treatment requires esophagocardiomyotomy and an antireflux procedure. However, when these operations fail, other procedures are needed. To summarize the experience treating children who have this condition, the authors reviewed retrospectively all case histories of patients treated from 1971 to 1996 at their hospital. METHODS: Three boys and a girl, ranging in age from 18 months to 11 years, were treated. All had multiple previous dilatations. Two then underwent operation using an abdominal approach for a Heller procedure and a posterior fundoplasty (Guarner operation). Two children were previously treated in another hospital. One underwent a Heller operation complicated by perforation of the anterior mucosa. The other had undergone three previous abdominal approaches for esophagocardiomyotomy and a Nissen fundoplication. Symptoms persisted and imaging and endoscopy showed stenosis in both patients. In the first patient an esophagocardioplasty with transverse closure (Wendel procedure) and a posterior fundoplasty was performed. In the second child, the three previous abdominal surgical approaches mandated a transthoracic approach with transdiaphragmatic latero-lateral esophagogastric anastomosis (Heyrowsky operation) and a modified Guarner operation using the remaining fundus and gastric body. RESULTS: There were no intraoperative or postoperative complications. Follow-up time ranged from 3 months to 17 years. All patients experienced dramatic relief of symptoms and satisfactory weight gain. No recurrence of symptomatology has occurred. CONCLUSIONS: Esophagocardiotomy associated with an antireflux procedure may be the first option in the surgical treatment of children who have achalasia. However, if this fails, esophagocardioplasty and the latero-lateral esophagogastric anastomosis associated with antireflux procedure may be successful alternatives.     

One-stage anterior urethroplasty

PURPOSE: A deficient urethral segment was replaced with penile skin during a 1-stage procedure in patients with a long, tight urethral stricture, multiple attempts at hypospadias repair or severe hypospadias and circumcision. MATERIALS AND METHODS: In 29 patients a pedicled circumferential strip of distal penile skin was used to construct a neourethral floor. The roof was formed by regeneration of the epithelium from the edges of the floor over Buck's fascia. In our series the urethra was reconstructed because of an anterior urethral stricture in 11 patients, multiple failed hypospadias repairs in 6 and severe hypospadias with circumcision in 12. RESULTS: A neourethra of sufficient caliber and length was constructed with minimal postoperative complications in all patients. There were 2 cases of urethrocutaneous fistula at the subcoronal region, 1 meatal stenosis, 1 persistent chordee and 1 small distal penile skin patch slough that required only prolonged dressings. Mean followup was 19 months. CONCLUSIONS: Our urethroplasty technique can be used to correct various types of anterior urethral stricture or hypospadias associated with insufficient penile or preputial skin.     

The effect of angelica polysaccharide on proliferation and differentiation of hematopoietic progenitor cell

When stenosis of the larynx and trachea involves loss to anterior support, this is usually corrected by an autograft of costochondral cartilage or of hyoid bone anchored with suture material. This paper describes an alternative technique employing a Vitallium alloy miniplate placed anterior to the airway as a means for providing support. This is placed over a fascial or auricular cartilage graft. Together, they provide a smooth scaffold for mucosal migration. Thirteen patients were treated at Indiana University Medical Center between 1991 and 1993 by means of this technique. Ten of the 13 patients (77%) achieved an adequate airway to allow decannulation. There have been no significant complications related to the use of the miniplate, and specifically, there have been no instances of infection or extrusion. It has been unnecessary to remove any of the miniplates. The Vitallium alloy miniplate offers unique advantages in laryngotracheal reconstruction in that it not only accurately approximates tissues, but it also provides external support to the airway.     

Advancement sleeve flaps for treatment of severe perianal Crohn's disease

BACKGROUND: Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn's disease. However, based on the success of rectal advancement flaps in Crohn's disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. METHODS: From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn's disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. RESULTS: There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn's disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P=0.008). CONCLUSION: Some patients with severe perianal Crohn's fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma.     

Management of persistent filtering cicatrix following cataract extraction

We used a safe and simple surgical technique in the management of persistent filtering cicatrices after cataract extraction. The edematous, friable filtering cicatrix was excised entirely and a healthy fornix-based conjunctival flap was sutured over the fistula. Invariably, the fistula was very small, usually only large enough to admit a 27-gauge needle. Of the 27 eyes treated with this technique, there were two failures, but no other complications.     

Development of a subdural vein thrombosis following aggressive factor VII replacement for postnatal intracranial haemorrhage in a homozygous factor VII-deficient infant

Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and may present a management dilemma in those who are unfit or unwilling for surgery. Video-assisted thoracoscopic surgery (VATS) has been advocated in the management of patients with broncho-pleural fistulae (air-leak persisting beyond 7 days): however the optimum time for surgical intervention remains unclear. We reviewed the records of 130 episodes of SP in 115 patients over a 2-year period to determine clinical course and outcome, particularly with respect to duration of air-leak. There were 90 first episodes and 40 recurrent episodes. Eighty-one episodes (62%) occurred in patients with underlying lung disease (secondary pneumothorax). Initial management consisted of chest-tube drainage in 104 episodes (80%) occurring in 90 patients, percutaneous needle aspiration in five patients (4%) and observation in 21 episodes (16%) in 20 patients. In the group treated with chest-tube drainage, there was spontaneous resolution of air leak and lung re-expansion in 90 episodes (87%). The overall incidence of broncho-pleural fistula was 34.6%. In the primary SP group. 75% of air-leaks ceased by 7 days and 100% by 15 days. In the secondary SP group, 61% of air-leaks resolved by 7 days and 79% by 14 days, after which time resolution of air-leak proceeded at a much slower rate. Five patients underwent surgery while nine patients were discharged with residual pneumothoraces. There were no major complications or mortality. Based on our findings, we advocate surgery for patients with air-leak persisting beyond 14 days, while favouring a conservative approach before this time, as the majority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days.     

Cartilage folding method for main bronchial stapling

Bronchopleural fistula is one of the most severe complications of lung operations. To prevent bronchopleural fistula, we modified the stapling technique to include folding of both sides of the cartilaginous main bronchus. This reduces the tension at the center of the membranous portion of the airway. From 1991 to 1994, this technique was performed in 7 patients. Despite the fact that 4 of these patients received adjuvant therapy, none had development of a bronchopleural fistula.