Biomedical subjects
Garret S Zallen
Publications and source records attributed to Garret S Zallen.
Cardiopulmonary resuscitation in patients with a Nuss bar--a case report and review of the literature.
Pectus excavatum (PE) is a common chest wall deformity that may produce a variety of physiological and psychological effects in children and adolescents. In addition, some of these patients have associated cardiac diseases (ie, mitral valve prolapse and Marfan syndrome). Recently, a minimally invasive surgical repair of PE that requires sternal bar placement has become increasingly frequent to enhance patients' cardiopulmonary functioning as well as their self-esteem. However, despite this innovative technique, it is possible for such patients to have a cardiac arrest while their sternal bar is in place. Whether the presence of a metal bar on the underside of their sternum may hinder resuscitative chest compressions (cardiopulmonary resuscitation) is an issue that concerns us, our patients, and their families; the answer requires further investigation. We present a 21-year-old man with PE who underwent a minimally invasive pectus repair but had a fatal cardiac event before bar removal. Paramedics conducting cardiopulmonary resuscitation on the patient later reported that they were unable to deliver effective cardiac compressions and that the sternal bar may have contributed to this.
Miniature access pectus excavatum repair: Lessons we have learned.
BACKGROUND: Pectus excavatum (PE) is the most common chest well deformity seen in children. In 1997, the Miniature Access Pectus Excavatum repair (MAPER) was presented by Nuss et al, adding a new option for PE repair. This operation entails placing a custom bent metal bar across the chest to mechanically raise the sternum and remodel the cartilage. The authors have added modifications to Nuss' original description of this operation in an attempt to optimize technique, minimize complications, and improve outcomes. METHODS: The authors have performed 52 MAPERs with an average operating time of 106 minutes, average length of stay of 3.9 days, and return to normal activities of 2 to 6 weeks. Modifications to Nuss' original description include preoperative evaluation consisting of an echocardiogram and pulmonary function tests (PFTs; with and without exercise and with and without bronchodilators), abandoning the use of routine preoperative computed tomography (CT) scans, the use of unilateral positive pressure insufflation of the hemithorax to provide visualization, and anesthesia using an epidural pain catheter (intraoperative and postoperative for 3 days). Intraoperatively, we use a 70 degrees thoracoscope for optimal visualization, and we have modified their location for optimal visualization. Additionally, the bars are secured with surgical wire, not absorbable suture, to avoid bar slippage. RESULTS: Postoperatively, we leave our bars in for 3 years and have had no recurrences. Furthermore, these patients require significant support during the time their bars are in place and occasionally require reoperation to fix symptomatic problems with their bar. CONCLUSIONS: Since the first description of the MAPER was presented more than 5 years ago, the operative treatment of PE has changed dramatically. The authors feel that the MAPER is superior to the open technique, and with the modifications they have implemented, complications have been minimized, and long-term results have been improved.
Diagnosing Hirschsprung's disease: increasing the odds of a positive rectal biopsy result.
BACKGROUND/PURPOSE: Rectal biopsies are performed as a definitive means of diagnosing Hirschsprung's Disease (HD) in children presenting with constipation. The authors hypothesized that key features in the history, physical examination, and radiographic evaluation would allow us to avoid unnecessary rectal biopsies. METHODS: A retrospective analysis was conducted on patients undergoing rectal biopsy between 1995 and 2001. Patients with HD were identified (n = 50), and a concurrent cohort of patients with idiopathic constipation (IC; n = 50) was selected. Pertinent features in patients with HD versus those with IC were cross tabulated using Pearson Chi2 testing (significance was P <.05). RESULTS: Sixty percent of patients with HD and 15% of patients with IC experienced onset of symptoms in the first week of life. HD patients more frequently experienced delayed passage of meconium (P <.05), abdominal distension (P <.05), vomiting (P <.05), and transition zone on contrast enema (P <.05). All patients with HD had one or more of these significant features. In contrast, only 64% of patients with IC had one or more of these features. The classic triad of symptoms (ie, delayed passage of meconium, vomiting, and abdominal distension) was present in 18%, and one or more of these symptoms was present in 98% of HD patients. In contrast, only 60% of patients with IC had a history of delayed passage of meconium, vomiting, or abdominal distension. CONCLUSIONS: A history of delayed passage of meconium, abdominal distension, vomiting or the results of a contrast enema identified all patients with HD and excluded HD in approximately 36% of patients with idiopathic constipation. The authors have shown that key features in a patient's history, physical examination, and radiologic evaluation can differentiate between HD and IC. In a child presenting with constipation and none of the above features, it is not necessary to perform a rectal biopsy to exclude HD.