Biomedical subjects
Publications and source records attributed to H C Filston.
Early ventilatory failure in an infant with EA/TEF may prove difficult to manage because of the low resistance "vent" provided by the TEF. In this Case Report Fogarty balloon occlusion of the vent was possible and aided management of the patient who was not a candidate for primary repair of the anomaly.
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Thirty-three neonates with disseminated intravascular coagulation were assigned randomly to one of three treatment groups: (1) exchange transfusion, (2) administration of fresh-frozen plasma and platelets, and (3) control (no therapy directed specifically at the coagulopathy). The three groups were comparable for degree of abnormality in initial coagulation studies and underlying pathologic processes. Shock was a common accompaniment of DIC and occurred in 85% of all infants. In all cases, underlying disease states and shock were treated aggressively. Resolution of DIC and survival were not different in the three treatment groups. Outcome of DIC was dependent on the success of treatment of the underlying pathologic process and aggressive supportive care, including restoration of blood pressure, but was not altered by therapy specifically directed at the coagulopathy.
A quadrant scheme is presented for estimating postoperative fluid volumes for replacement of internal fluid shifts (third space losses) in pediatric surgical patients undergoing major intraabdominal surgery. The benefits derived from using a prescribed postoperative fluid management program that includes this quadrant scheme are determined by analyzing a series of 50 consecutive patients managed by five senior general and thoracic surgical house officers. Although the program tended to overestimate the fluid needs of the patients relative to a predetermined optimal urine output level, all but two patients with septic complications were hemodynamically stable and none had complications due to the fluid administration program.
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Although anomalies of rotation and fixation of the gastrointestinal tract are recognized to be associated frequently with anomalies of the abdominal wall and diaphragmatic hernia, the frequency with which these common anomalies are associated with other congenital and acquired lesions of the gastrointestinal tract has not been sufficiently emphasized. Sixty-two percent of our series of 34 patients were associated with such lesions as upper gastrointestinal atresias and stenoses, intussusception, and Hirschsprung's disease. The embryologic and anatomic features of rotational anomalies, their clinical presentation, and radiologic features are presented with the suggestion that knowledge of this information, along with the appreciation of the frequent association of malrotation with other common congenital and acquired abnormalities, will help to prevent the devastating morbidity and mortality of undiagnosed midgut volvulus.
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Internal pancreatic fistulas have only recently been recognized as distinct entities in children. Unless their pathophysiology is understood they can present the clinician with a diagnostic dilemma. Recently, these entities have been better defined in the adult literature and significant improvement made in treatment. We report a case of a child with pancreatic ascites in whom endoscopic retrograde cholangiopancreatography significantly aided the diagnosis and the operative management. An outline of recommended management of pancreatic lesions in children is presented including internal pancreatic fistulas.
The indications for major hepatic resections in 32 patients and the results are presented. Twelve right lobectomies, eight partial left lobectomies, five left lobectomies, four extended right lobectomies and three partial right lobectomies were performed with a 46% complication rate and an operative mortality rate of 12.5%. Ten primary liver cancers, 12 metastatic lesions, four hemangiomas and six "benign" lesions were removed. Of seven patients with hepatomas, four are alive at an average of 24 months postresection and three have no evidence of recurrence. Of 11 adult patients with metastatic lesions, six are alive at an average of 27 months postresection and three patients have no evidence of recurrence. All four patients with hemangioma are alive at an average of seven years. As in other series, our experience has increased with seven resections prior to 1970 and 25 since. Operative mortality has decreased in that period of time (42% to 4%); however, our complication rate in survivors has remained elevated (25% to 50%). Our experience agrees with others that cautious selection of patients for resection of malignant tumors of the liver can extend survival.
Perforation of the duodenum is a serious complication of transpyloric tube feeding in infants of low birth weight. Polyvinyl chloride and (less commonly) silicone tubes have been implicated. Altered radiographic configuration of the tube in the region of the superior or inferior flexure, associated with clinical deterioration, pneumoperitoneum, peritonitis, or a retroperitoneal fistula, is diagnostic of duodenal perforation. The configuration of the tube may vary during uncomplicated transpyloric alimentation and is frequently incompatible with the expected anatomical course. Contrast examination may demonstrate normal anatomy or mobility of the distal duodenal loop as an adaptation to rigidity of the tube. The possibility of perforation appears to be increased at or adjacent to the flexures.
Percutaneous infraclavicular cannulation of the subclavian vein in even the tiniest infants can be performed with safety and ease using a plastic cannula metal needle stylet and following plastic catheter. This route for achieving superior vena caval catheterization provides a most satisfactory method for central pressure monitoring, long term antibiotic administration, total parenteral nutrition, and exchange transfusion. Few serious complications have been noted in over a hundred infant cannulations. The procedure can be performed in the intensive care nursery with a success rate of over 95%. Sepsis rates in clean cases are acceptably low. Most sepsis is due to other clearly identifiable sources of infection in these already critically ill infants.
Severe stress ulceration or stress gastritis may occasionally produce uncontrollable gastric hemorrhage in the pediatric age group. Modern arteriographic techniques utilizing selective embolization to occlude demonstrated bleeding arteries can successfully control such hemorrhage and avoid emergency destructive surgical resection. A 10-yr-old boy, in whom a previous 80% gastric resection failed to control life threatening hemorrhage, is presented, with roentgenographic demonstration of the procedure and the successful control of his gastric bleeding.
Survival of infants with necrotizing enterocolitis may be complicated by intestinal stricture(s) as a result of healing of ischemic segments of bowel. An asymptomatic cecal stenosis not visible on barium enema was identified at operation for reestablishment of intestinal continuity. Infants recovering from acute necrotizing enterocolitis deserve continued surveillance for mechanical and functional abnormalities of the gastrointestinal tract. Patency of the intestinal lumen distal to the ostomy site should be clearly demonstrated by the surgeon when continuity is reestablished.
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Although most infant airway and ventilatory problems will be best solved by the use of endotracheal tubes, clear-cut indications for tracheostomy exist. Past reticence to use tracheostomy for infants has been due mainly to the fear of decannulation problems. Recognition of obstructive airway lesions, particularly the lumen-narrowing tracheal stomal granuloma, has been facilitated by the routine use of the newer infant bronchoscopes with optical telescopes. Successful decannulation begins with proper tracheostomy technique, and continues through tracheostomy management and a well-conceived decannulation program. Decannulation should include evaluation of the structure and function of the airway endoscopically and it may include translaryngeal endoscopic resection or formal surgical removal of any obstructing lesions. Experienced nursing personnel are essential to the entire program.