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International Abstracts602
experience and strategy in the management of pulmonary hydatid
disease. Sixty-six patients with 83 pulmonary hydatid cysts underwent
surgical treatment. Double-lumen endotracheal tubes were used in
children over 12 years of age. There were 38 boys and 28 girls with
a mean age of 9.6 F 7 years (range 5-15 yrs). Of the 83 cysts, 61 were
intact and 22 were ruptured. Isolated pulmonary hydatid cysts were seen
in 61 patients (92.4%), while 5 patients (7.6%) had combined pulmonary
and hepatic cysts. Lateral thoracotomy was performed in 54 patients
(82%), thoracophrenotomy in 5, bilateral thoracotomy 4, and median
sternotomy in 3 patients. Cystectomy and capitonnage were performed in
58 cysts, cystotomy alone in 21, and resection techniques in 4 patients.
There were 8 postoperative complications in 7 patients. Atelectasis was
the most common complication. It is concluded that surgery is the
treatment of choice for most patients with pulmonary hydatid disease.
The use of double-lumen tubes may decrease intra- and postoperative
complications. Thoracophrenotomy can be chosen as the surgical proce-
dure in the management of simultaneous pulmonary and hepatic cysts.—
Thomas A. Angerpointner
The vagus and recurrent laryngeal nerves in experimental congenitaldiaphragmatic hernia
Martinez L, Gonzales-Reyes S, Burgos E, et al. Pediatr Surg Int 2004
(April);20:253-257.
Nitrofen induced congenital diaphragmatic hernia (CDH) in rats shows
associated malformations similar to those seen in human CDH. This
includes a disturbed regulatory action of the neural crest (NC) on the
organogenesis of the pharyngeal pouch and some derivatives. Because even
the vagus and the recurrent laryngeal nerves derive from the NC, the
authors investigated whether these nerves are anatomically abnormal in
CDH fetal rats. Because CDH is often associated with gastroesophageal
reflux (GER), disturbance of NC and abnormality of vagus and recurrent
laryngeal nerves may explain esophageal dysfunction.
One group of rats received nitrofen, another group served as controls.
The fetuses were recovered one day before term, killed and evaluated for
the presence of CDH. A thoracic block was sectioned, stained with HE and
assessed for the vagus and recurrent laryngeal nerves. A computer-assisted
three-dimensional reconstruction was done.
Nine control fetuses without CDH were compared with 9 fetuses
with CDH. The anatomy of the vagus nerves and the recurrent laryngeal
nerves was normal in the control group, but were grossly abnormal in
seven of nine fetuses with CDH. In 4 fetuses, one of the vagus trunks
was absent. Two of them presented an additional absence of the recurrent
laryngeal nerve on the side of the normal vagus. In two animals a
marked hypoplasia of the vagus trunk was found. One of these two and
one further rat showed anomalies in the course of one of the nerves. In
three animals, even an aberrant right subclavian artery was mentioned.
GER after repair of CDH is explained by malposition of the
gastroesophageal junction or increased abdominal pressure. But sometimes
a dilated, fluid- or air-filled esophagus is found, suggesting functional
disturbance of the esophagus himself. The presented work showed gross
malformation of the NC-derived vagal and recurrent laryngeal nerves.
Anomalies of this nature may even be present in newborn babies with
CDH. If these anomalies have counterparts in human, GER in this patients
may derive more from esophageal innervational failure than from
extraesophageal reasons.—Peter Schmittenbecher
Congenital diaphragmatic hernia: associated anomalies and antenataldiagnosis
Bedoyan JK, Blackwell SC, Treadwell MC, et al. Pediatr Surg Int 2004
(March);20:170-176.
The neonatal mortality rate of all antenatally diagnosed isolated congenital
diaphragmatic hernia (CDH) is still ranging from 50% to 76%, but survival
is enhanced by ECMO, NO and in utero fetal surgery. The authors reviewed
CDH cases from their area’s healthcare facilities to get sufficient database to
counsel the specific population, to direct available therapy and to identify
patients that may benefit from special therapies.
Within 14 years, 77 patients with CDH were presented to two children
hospitals. Data on maternal and infant demographics, prenatal fetal
ultrasound parameters, outcome of pregnancy, associated anomalies, and
infant hospital course were collected.
6.5 F 1.9 cases per year were seen. Mean age of mothers was 27.4
years, there was no history of stillborn. 89% of pregnancies resulted in live
births, 1.4% in stillbirth and 9.6% in voluntary interruption. Survival of
N30 days was 53.8%, neonatal death 30.8% and late death 1.5%. The fact of
prenatal diagnosis did not influence survival. The fetal ultrasound
parameters CC/AC (chest circumference/abdominal circumference) and
CC/HC (.../head circumference) were useful to predict prognosis, because
all cases with a CC/AC ratio b0.95 and a CC/HC ratio b0.8 died, but 2/3 of
children with ratios above these levels survived.
Birthweight and gestational age of survivors and non-survivors did not
differ. Nearly 2/3 of the children went on ECMO. 52% of ECMO children
and 77% of non-ECMO patients survived. Forty-three percent had
associated anomalies. Cardiac anomalies were most frequent (52%),
followed by muscoloskeletal (20%), CNS (12.5%), chromosomal (6.3%),
genitourinary (5%) or gastrointestinal anomalies (3%). Any major
associated anomaly resulted in a poorer outcome (43.5% survival),
whereas survival in isolated CDH was 70%, without a difference between
left- and rightsided defects. The worst outcome indicators were pulmonary
hypoplasia and the presence of liver, stomach, or spleen in the thorax.
Comparing the data with a recent metaanalysis of mortality factors,
survival rates were found uniformly higher. Fetal ultrasound parameters
indicating pulmonary hypoplasia were helpful to calculate the prognosis
as it is known from the literature for similar parameters like lung area to
head circumference ratio (LHR). Once again, liver herniation especially
in left sided hernia was a poor prognostic parameter. Fetus with left-
sided CDH, liver herniation and low LHR benefit from newer therapeutic
strategies like ECMO. Contrary to other studies, prenatal diagnosis did
not worse the prognosis. This may be caused by the growing number of
prenatal examinations and diagnosis.—Peter Schmittenbecher
Alimentary Tract
Tracheoesophageal fistula due to disc-battery ingestion
Alkan M, Buyukyavuz I, Dogru D, et al. Eur J Pediatr Surg 2004 (August);
14:274-278.
Ingestion of a disc-battery can lead to hazardous complications
including tracheo-esophageal fistula (TEF), particularly if the battery
is impacted in the esophagus. Urgent esophagoscopic removal of the
battery is essential in these cases. Persisting respiratory symptoms and/or
feeding problems after removal should alert the surgeon to evaluate
for TEF. Esophagography and/or esophagoscopy should be performed.
Once TEF is identified, conservative treatment is the initial treatment
of choice. Delayed surgical closure is necessary if spontaneous closure
does not occur. The authors present a case of TEF secondary to disc-
battery ingestion with review of the current literature and discuss the
management of this potentially life-threatening complication.
—Thomas A. Angerpointner
Post-traumatic duodenopancreatectomy in a child
Salman FT, Emre A, Abbasoglu L, et al. Eur J Pediatr Surg 2004
(August);14:287-289.
The authors report on an 5-year-old boy who complained of severe
abdominal pain after a car accident. He was sitting on the lap of the
driver and his abdomen was pressed closely between the pregnant driver
and the steering wheel. At laparotomy, associated injuries of the
duodenum and the pancreas were detected which could not be repaired.
The transsected pancreas and extensive duodenal injury necessitated a