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Biomedical subjects

Martin S Keller

Publications and source records attributed to Martin S Keller.

11 recordsLinked to original sources
PubMed2004

Management of penetrating colon and rectal injuries in the pediatric patient.

PURPOSE: Management of civilian penetrating colon injuries in the adult has evolved from the universal use of fecal diversion to the highly selective use of colostomy. We hypothesized that a similar management approach was appropriate for the pediatric population. METHODS: A retrospective review of pediatric patients (age <17 years) with a penetrating colorectal injury was performed at six Level I trauma centers for the period January 1990 through June 2001. RESULTS: For the period of review, 53 children with a penetrating colorectal injury were identified. Firearms caused 89 percent of the injuries. The colon was injured in 83 percent (n = 44) of patients and the rectum in 17 percent (n = 9) of patients. The colorectal injury was managed without colostomy in 62 percent (n = 33) and with colostomy in 38 percent (colon = 11, rectum = 9). All rectal injuries were treated with colostomy. The hospital length of stay was longer in the colostomy group (17.6 days vs. 11.4 days). The complication rate was higher in the colostomy group (55 percent vs. 27 percent), which included two patients with stoma-related complications. There was no mortality in this series. CONCLUSIONS: Primary repair was used safely in most cases of civilian penetrating colon injuries in the pediatric population. All rectal injuries were treated with colostomy in this series. Fecal diversion was used selectively. Colostomy was performed for selected cases of colon wounds associated with shock, multiple blood transfusions, multiple other injuries, extensive contamination, and high-velocity weapons. In the absence of these associated factors, primary repair appears justified.

Adolescent↗
PubMed2004

The utility of routine trauma laboratories in pediatric trauma resuscitations.

BACKGROUND: Because of the difficulties in evaluating injured children, screening blood tests are recommended. METHODS: Resuscitation blood tests (complete blood count, chem12, coagulation panel, urinalysis) were reviewed for abnormality frequency, injury correlation, managements, and outcome. RESULTS: Panels were obtained on 240 children (age < 16 years) meeting trauma system criteria. Abnormalities were identified as follows: white blood cell/hematocrit/platelets (41%, 27%, 1%), Na/K/Cl/CO(2) (3%, 30%, 23%, 14%), blood ureal nitrogen/creatinine (6%, 0%), prothrombin time/international normalized ratio/partial thromboplastin time (22%, 16%, 6%), aspartate aminotransferase/alanine transferase (43%, 35%), amylase (2%), glucose (77%), and urinalysis (31%). Organ-specific chemistries predicted injury poorly. Transaminasemia correlated with liver injury when levels exceeded 400 U/L. Two children (1%) with hyperamylasemia had abdominal injuries. Coagulation abnormalities correlated with intracranial injury (43%) and Glasgow Coma Scale (GCS 3 to 8; 56%, GCS 9 to 14; 20%, GCS 15; 14%, P <0.05). Only 25 (10%) had interventions for test abnormalities (11 transfusions, 8 fresh frozen plasma, 3 tests repeated, 3 KCl). CONCLUSIONS: Routine laboratory panels are little value in the management of injured children.

Acrylic Resins↗
PubMed2004

Blunt injury to solid abdominal organs.

Injuries to the solid abdominal viscera (spleen, liver, kidney, pancreas) are common in children sustaining trauma by blunt mechanisms. Success with nonoperative management of these injuries has led to recent extensions of this approach to the management of higher-grade more complicated injuries typically treated operatively. This review will discuss the current status of evaluation, management and outcome of children sustaining blunt injury to solid abdominal organs.

Abdominal Injuries↗
PubMed2004

Functional outcome of nonoperatively managed renal injuries in children.

BACKGROUND: This study aimed to define better the functional outcome of nonoperatively managed renal injuries in children. METHODS: All children who had blunt renal trauma managed nonoperatively were reviewed for injury grade, blood urea nitrogen (BUN), creatinine, blood pressure, and percentage of function according to technetium-99m-dimercaptosuccinic acid renal scan after complete healing. RESULTS: Over a 2-year period, 17 children (mean age, 10.4 years) were managed conservatively for their renal injuries. There were two grade 2, two grade 3, nine grade 4, and four grade 5 injuries. Complete healing was documented in all cases within 3 months after injury. Renal scarring and volume loss were evident for all healed high-grade injuries (grades 4 to 5) at follow-up imaging. Technetium-99m-dimercaptosuccinic acid scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (44.7 +/- 8.4% function for grades 2 and 3, 41.8 +/- 9.2% for grade 4 vs 29.5 +/- 7.9% for grade 5). Only two children (22%), however, with grade 4 injury had severe compromise of function (<30%). At the follow-up visit, all the children were asymptomatic and normotensive. None had abnormal BUN or creatinine (mean BUN, 10.5 +/- 5.1 mg/dL; mean creatinine, 0.6 +/- 0.2 mg/dL). CONCLUSIONS: The functional outcome for children with nonoperatively managed kidney injuries is good and correlates with injury grade. Children with grades 2 to 4 injuries managed conservatively retain near normal function. Those with grade 5 injuries have a loss of function attributable to scarring and parenchymal volume loss. Long-term follow-up evaluation of these children may be warranted.

Adolescent↗
PubMed2003

Predictors of surgical outcome for complicated pneumonia in children: impact of bacterial virulence.

The charts of 110 children with community acquired bacterial pneumonia were reviewed. A subset of children who required surgical intervention for empyema or parapneumonic effusion was identified. Patients were divided into two treatment groups: antibiotics/tube thoracostomy alone (group 1) versus operative intervention (group 2). Overall, 33 (30%) of the children required surgical intervention for complications. Seventeen (15%, group 1) were successfully treated with antibiotics/tube thoracostomy alone, while 16 (15%) in group 2 were treatment crossovers, failing this initial therapy. Of group 2 children, 4 (25%) underwent thoracotomy and lobectomy, while 12 (75%) underwent video-assisted thoracoscopic surgery (VATS). Although group 2 children were younger than those in group 1 (4.4 +/- 3.6 versus 6.3 +/- 4.1 years, p<0.05) and had longer hospitalizations (20.1 +/- 10.1 versus 8.2 +/- 3.9 days, p<0.05), symptom duration, preoperative antibiotics, fibrinolytic use, and leukocytosis were similar (p>0.05). Group 1 children had 13 (76%) positive cultures, 92% with pan-sensitivities, in contrast to group 2, which had 12 (75%) positive cultures, but only 33% were sensitive to first-line antibiotics (p<0.01). Group 2 patients were also more likely to have complex multi-loculated empyemas, pneumatoceles, or pulmonary necrosis identified on imaging studies (100% versus 24%, p<0.01). These data suggest that the natural history of pneumonia in children is heavily influenced by bacterial virulence. Tube thoracostomy and appropriate antibiotics remain effective for pan-sensitive, simple parapneumonic effusions and empyema. Complex parapneumonic effusions and empyema, however, which occur more frequently in the setting of first-line antibiotic resistance, often fail more conservative managements and may be best treated by earlier operative debridement.

Adolescent↗
PubMed2003

The impact of surgery on infants born at extremely low birth weight.

PURPOSE: The aim of this study was to determine the outcome of extremely low-birth-weight infants (ELBW) requiring surgical interventions for the complications of prematurity METHODS: One hundred eighty-seven consecutive infants with a birth weight less than 1,000 g treated over a 5-year period were reviewed. Outcome variables included number and types of surgical procedures; length of stay; survival rate and; pulmonary, neurologic, and gastrointestinal morbidity. RESULTS: Surgical interventions were required in 66 (35%) infants (group S) weighing less than 1,000 g at birth (33% necrotizing enterocolitis/bowel perforation, 36% patent ductus arteriosus, 56% other). Overall mortality rate for group S infants was 23% compared with 22% for those not requiring surgery (group NS; P >.05). Mortality rate rose to 38% for those infants undergoing procedures for necrotizing enterocolitis/bowel perforation (P <.05). Although neurologic and pulmonary morbidity for the entire population were high, there was no difference in their incidence between surgical and nonsurgical groups (29% v 26% and 44% v 65%, group S v group NS, respectively; P >.05). CONCLUSIONS: These data suggest an improving outcome for ELBW infants. Common associated morbidities of prematurity do not appear adversely affected by surgical interventions supporting an aggressive approach to the care of these infants at the extreme of life.

Cohort Studies↗
PubMed2002

Aortic suspension (aortopexy) for severe tracheomalacia in infants and children.

BACKGROUND: Tracheomalacia with anterior great vessel compression is a common disorder in infants and children, which can lead to life-threatening airway occlusion. In this study, a large number of patients underwent anterior aortopexy to provide a more normal distal airway. METHODS: Thirty-two infants and children with tracheomalacia associated with esophageal atresia-tracheoesophageal fistula (18), vascular ring (8), abnormal innominate artery takeoff (4), and primary (2) were evaluated with bronchoscopy, magnetic resonance imaging, and pulmonary functions. Aortopexy was accomplished through left thoracotomy and suture fixation of the aorta and innominate artery to the posterior sternum. RESULTS: Intraoperative bronchoscopy showed marked improvement in airway caliber and rigidity, and no patients had further obstructive episodes. Forced expiratory volume improved from 52% +/- 4% of predicted to 82% +/- 3%. CONCLUSIONS: Aortopexy is a simple procedure for the treatment of distal tracheomalacia that is immediately effective and provides permanent relief of obstructive episodes.

Airway Obstruction↗
PubMed2002

Adverse effects of liver dysfunction and portal hypertension on intestinal adaptation in short bowel syndrome in children.

BACKGROUND: The effects of liver dysfunction and portal hypertension on intestinal adaptation in short bowel syndrome are generally unknown. The presence of these disorders may adversely affect the ability to wean these patients from parenteral nutrition. METHODS: Forty-two infants with short bowel syndrome were placed in one of three Child's classifications, depending on serum bilirubin, prothrombin time, ascites, albumin, and liver biopsy, and compared for time to diet tolerance, time required for parenteral nutrition, and survival. A subgroup of these patients also underwent portal pressure measurement, which was combined with liver biopsy results to compare three groups for the same parameters. RESULTS: Survival was Child's class A 100%, B 84%, C 61%, while time to feeding tolerance was A 16.3 days, B 20.0 days, C 28 days, and total parenteral nutrition time was A 80.0 days, B 98.0 days, C 100.0 days. In the groups that underwent portal pressure measurement, the survival was group I (normal biopsy and pressure) 100%, group II (abnormal biopsy and normal pressure) 90%, group III (abnormal biopsy and pressure) 66%, while time to feeding tolerance was I 15.0 days, II 18.0 days, III 24.0 days, and total parenteral nutrition time was I 72.0 days, II 94.0 days, III 184.0 days. CONCLUSIONS: Cholestatic liver disease, especially associated with portal hypertension adversely affects bowel adaptation in short bowel syndrome.

Cholestasis, Intrahepatic↗
PubMed2002

Blunt renal trauma in children: experience with conservative management at a pediatric trauma center.

BACKGROUND: The authors reviewed the outcome for children with blunt renal injury managed with a nonoperative protocol at their pediatric trauma center. METHODS: Fifty-five consecutive children aged 0.5 to 17 years with blunt renal injury managed over a 14-year period were reviewed. All patients were evaluated with computed tomographic scanning. Injuries were graded according to the American Association for the Surgery of Trauma Organ Injury Scale. RESULTS: Forty-eight of 55 children (87%) were successfully managed nonoperatively. Overall, there were 5 grade I, 13 grade II, 18 grade III, 14 grade IV, and 5 grade V injuries. All children with grades I and III injuries were successfully managed nonoperatively. Two (6%) of these children required transfusion. Only four (29%) children with grade IV and three (60%) with grade V injuries required surgical interventions (one nephrostomy, six nephrectomies). Excluding patients with continuing hemorrhage, only 2 (14%) of 14 with high-grade injuries required surgical intervention (1 nephrostomy, 1 nephrectomy). Clearance of gross hematuria correlated with severity of injury and was prolonged in grade IV and V compared with grade I to III injuries (6.8 +/- 2.7 vs. 3.2 +/- 2.1 days, respectively; p < 0.05). Fifty-one children (93%) available for follow-up were normotensive with normal renal function. CONCLUSION: These data support the use of conservative management for all grades in stable children with blunt renal injury. Transfusion requirements, operative rates, and outcome are consistent with other pediatric solid organ injuries.

Adolescent↗