Biomedical subjects
Geoffrey K Blair
Publications and source records attributed to Geoffrey K Blair.
Postnatal spontaneous resolution of congenital cystic adenomatoid malformations.
PURPOSE: Although antenatal resolution of congenital cystic adenomatoid malformations (CCAMs) is well documented, complete spontaneous postnatal resolution is rare, its existence even questioned by some. METHODS: All cases of antenatally diagnosed CCAMs over 7 years were retrospectively reviewed. Inclusion criteria were the following: (1) antenatal diagnosis of CCAM, (2) persistence on postnatal imaging, and (3) subsequent spontaneous resolution on postnatal imaging. RESULTS: Of 56 antenatally diagnosed CCAMs, 2 patients were identified. Both had macrocystic lesions. In case 1, the CCAM that filled the hemithorax on antenatal ultrasound was smaller on postnatal chest radiograph and disappeared by age 37 months on computed tomography. Case 2 had significant reduction of the CCAM at birth (persistence of the lesion on initial radiographs and ultrasound was documented). By 5 months, the lesion was not evident on computed tomography. Neither case was associated with symptoms, polyhydramnios, hydrops, or other abnormalities. CONCLUSIONS: In patients with an antenatal diagnosis of CCAM, spontaneous resolution may occur postnatally in 4% of cases. Significant reduction in CCAM size may portend possible disappearance and therefore warrants an observational period before resection.
Can we predict the failure of thoracostomy tube drainage in the treatment of pediatric parapneumonic collections?
BACKGROUND/PURPOSE: Tube thoracostomy is a standard method of treating pediatric parapneumonic collections. Despite recent work denoting thoracoscopy as a superior method of treatment, few studies have looked at factors predictive of tube thoracostomy failure. We reviewed parapneumonic collections initially treated with tube thoracostomy to identify such factors. METHODS: Nontuberculous parapneumonic collections treated initially with tube thoracostomy over a 10-year period were reviewed. A "failed primary tube thoracostomy" was defined as the presence of worsening clinicoradiological signs requiring a further chest procedure (ie, thoracoscopy, thoracotomy, or second thoracostomy). RESULTS: Fifty-eight patients were identified. Forty-three percent failed primary tube thoracostomy. Within group F (failure group), 32% of patients had a concomitant medical condition (P < .001). Sixty percent of group F patients had duration of symptoms for more than 1 week compared with only 24% of group S (successful group) (P < .001). CONCLUSIONS: Our results suggest that primary treatment of parapneumonic collections with tube thoracostomy is likely to be unsuccessful in patients who are symptomatic for more than a week or who have a concomitant medical condition. A more aggressive primary surgical intervention is suggested for this group.
Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard?
BACKGROUND/PURPOSE: Gastrostomy tube insertion is frequently performed in children. Percutaneous endoscopic gastrostomy (PEG) insertion, considered by many to be the "gold standard," is unavoidably associated with a risk of intestinal perforation and frequently requires a second anesthetic for its replacement with a low-profile "button." We hypothesized that a laparoscopic technique with low-pressure insufflation would yield comparable outcomes, a lower procedural complication rate, and require fewer anesthetics per patient. METHODS: A retrospective review of all surgeon-placed gastrostomy tubes (exclusive of those associated with fundoplication or other procedures) between January 2002 and December 2003 was undertaken. Data collected included type of procedure (PEG vs laparoscopic), indication, patient demographics (including neurologic comorbidity), operative time, complications (procedure-specific and nonspecific), and number of procedural anesthetics to "achieve" a low-profile tube. Groups were compared by univariate and multiple logistic regression analyses. RESULTS: One hundred nineteen gastrostomy tubes (26 laparoscopic = 21.8%) were inserted. The PEG and laparoscopic gastrostomy groups were comparable from the perspectives of age, size, indications for tube placement, and operative time. The complication rate after PEG placement was significantly higher than after LG (14% vs 7.7%; P = .023), and 72 (77.4%) of PEG patients required a second anesthetic for tube change. CONCLUSIONS: Laparoscopic gastrostomy tube insertion is safe and easy to perform, with outcomes comparable to that of PEG tube insertion. It obviates the need for a second procedural anesthetic and may emerge as the gold standard for gastrostomy tube placement.
Does the transition zone reliably delineate aganglionic bowel in Hirschsprung's disease?
BACKGROUND: Knowledge of the extent of aganglionic bowel is important for preoperative planning of trans-anal surgery in patients with Hirschsprung's disease (HD). OBJECTIVE: To evaluate the accuracy of the transition zone, as identified by contrast enema study, for identifying the extent of aganglionic bowel. MATERIALS AND METHODS: A total of 32 patients with preoperative contrast enema studies and pathologic identification of aganglionic extent were reviewed. Two pediatric radiologists independently reviewed the contrast enema studies. The radiographic transition zone was compared to the pathological extent of aganglionic bowel. RESULTS: Radiologist agreement of the site of transition zone on contrast enema was 90.6%. The concordance between the radiographic transition zone and pathologic extent of aganglionic bowel was 62.5%. The subgroup of patients with long-segment HD revealed a concordance of only 25%. CONCLUSION: Contrast enema delineation of the transition zone in HD needs to be regarded with caution. This is especially true in long-segment disease, where knowledge of the extent of aganglionic bowel is most crucial to surgical planning.
Outcomes in esophageal atresia and tracheoesophageal fistula.
BACKGROUND/PURPOSE: The purpose of this analysis was to investigate outcomes in newborns with esophageal atresia (EA) or tracheoesophageal fistula (TEF) with respect to prognostic classifications and complications. METHODS: Charts of all 144 infants with EA/TEF treated at British Columbia Children's Hospital (BCCH) from 1984 to 2000 were reviewed. Patient demographics, frequency of associated anomalies, and details of management and outcomes were examined. RESULTS: Applying the Waterston prognostic classification to our patient population, survival rate was 100% for class A, 100% for class B, and 80% for class C. The Montreal classification survival rate was 92% for class I and 71% for class II (P =.08). Using the Spitz classification, survival rate was 99% for type I, 84% for type II, and 43% for type III (P <.05). The Bremen classification survival rate was 95% "without complications" and 71% "with complications." Complications included stricture (52%), gastroesophageal reflux (31%), anastomotic leakage (8%), recurrent fistula (8%), and pneumonia (6%). Seventeen patients underwent fundoplication for gastroesophageal reflux, 16 pre-1992 and one post-1992. CONCLUSIONS: Comparing the major prognostic classifications, the Spitz classification scheme was found to be most applicable. In our institution, the trend in management of gastroesophageal reflux after repair of EA/TEF has moved away from fundoplication toward medical management.
Toward evidence-based best practices in neonatal surgical care-I: The Canadian NICU Network.
BACKGROUND/PURPOSE: The Canadian Neonatal Network collects clinical data prospectively on every admission to each of its 17 tertiary level units in Canada. The purpose of this study was to interrogate the network database to determine case volumes, outcomes, and resource utilization for several neonatal surgical conditions. METHODS: The network database was used to measure a population-based, profile of incidence, outcome and resource utilization over a 22-month period for the following International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes: 741, spina bifida; 748.4, congenital cystic lung disease; 750.3, tracheoesophageal fistula; 751.1, atresia/stenosis of small intestine; 751.2, atresia/stenosis of large intestine/imperforate anus; 751.3, Hirschsprung's disease; 756.6, anomalies of the diaphragm; 756.7, anomalies of the abdominal wall. Also, all infants receiving extracorporeal membrane oxygenation (ECMO) during the study period were identified. RESULTS: Case volumes corresponding to each diagnostic code were as follows: 741 (104), 748.4 (12), 750.3 (124), 751.1 (142), 751.2 (121), 751.3 (67), 756.6 (88), 756.7 (151), ECMO cases (28). As a group, infants in the database who required major surgery consumed a disproportionate share of resources and had poorer outcomes than those who did not require major surgery. CONCLUSIONS: The Canadian Neonatal Network database enables population-based outcomes analysis for specific diagnoses, which, if supplemented by additional pre-and postnatal data fields for surgical conditions, could contribute to the determination of evidence-based best practices for these patients.
Avoiding stitch abscesses in subcuticular skin closures: the L-stitch.
A potential problem with the standard method of skin closure in pediatric surgery is the development of a skin abscess. To avoid this problem, we introduce a new stitch--the L-stitch. The technique involves passing the suture subcuticularly at the end of the incision and redirecting the needle at a 90 degree angle from the previous suture, before bringing it out to the skin surface. This stitch can be used in place of the initial and finishing knot of a running suture. It takes less time to perform than a square or a surgeon's knot and is less bulky. This technique is straightforward and, when used in conjunction with adhesive skin closure strips, provides strong, reliable skin closure, yielding excellent cosmetic results.
Pediatric surgical images: PET evaluation of papillary thyroid carcinoma recurrence.
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