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PubMed1992

[Congenital diaphragmatic hernia. Value of preoperative stabilization].

Seventy-two patients with congenital diaphragmatic hernia (CDH) diagnosed in the first 12 hours of live have been reviewed retrospectively. Forty-eight patients born before 1985 (group I) were compared to 24 patients born between 1985 and 1989 (group II). The management was different for the 2 groups. Group I was operated on immediately. For group II, delayed surgery after stabilization was preferred. For this group, stability was sought before, during and after surgery. Therapy was first aimed at optimizing ventilation and oxygenation by way mechanical ventilation. Pharmacologic agents were used in an attempt to decrease pulmonary vascular resistance and improve cardiac output. The survival rate was 37.5% before 1985, 62.5% after 1985 (P less than 0.01). Main prognostic factors were Apgar score, paCO2, pH, ventilation index, alveolar-arterial difference in oxygen and oxygenation index. The stabilization before surgery improved the survival rate.

Carbon Dioxide↗
PubMed1986

Evaluation of diaphragmatic contractility in patients with chronic obstructive lung diseases.

The indices of diaphragmatic contractility and respiratory ventilation were studied in 31 males with chronic obstructive bronchitis distributed into 2 groups: with hypercapnia (PaCO2 56.3 +/- 0.4 mm Hg) and normocapnia (PaCO2 42.7 +/- 1.4 mm Hg), with reduction of FEV1/VC to 42% and 52% of the due value, Pdimax to 63.4 +/- 5.3 cm H2O and 73.4 +/- 6.1 cm H2O. The plasmatic theophylline concentration 21.19 +/- 1.06 mkg/ml was maintained in five patients with hypercapnia for 10 days by intravenous administration of aminophylline. FEV1 and VC increased by 5% and 8% respectively, Pdimax by 59%, TTdi decreased from 0.10 +/- 0.02 to 0.06 +/- 0.01, and PaCO2--to 44.7 +/- 1.8 mmHg. Vt/Ti did not change significantly. Thus, in patients with irreversible bronchial obstruction the decrease of diaphragmatic contractility leads to the development of arterial hypercapnia. The maintenance of therapeutical concentration of theophylline in blood plasma permits to improve the ventilation function of respiratory muscles and normalize the PaCO2 level.

Adult↗
PubMed1976

Pregnancy in renal transplant recipients.

Of the 48 female patients attending the outpatient clinic of the Johannesburg General Hospital Transplant Unit between January 1971 and December 1974, 10 became pregnant. Fifteen pregnancies were recorded, 6 of which ended in abortions. Ten infants were born from the remaining 9 pregnancies and 4 (40%) died in the neonatal period. The main cause of neonatal death was prematurity. One major congenital anomaly, a diaphragmatic hernia, was found. Maternal complications were mild and easily controlled, urinary infection being the commonest. One patient showed a moderate reduction in renal function. Obstruction of labour by the transplanted kidney was not encountered, and the two Caesarean sections were performed for obstetrical reasons unrelated to the renal transplant.

Abortion, Therapeutic↗
PubMed1976

Gastric remnant carcinoma.

Over 1200 cases of carcinoma of the gastric remnant have been reported in the literature. There is an increase of this type of carcinoma in postoperative stomachs with atrophic gastritis and intestinal metaplasia. The cause and effect relationships remain to be fully elucidated. In patients with late postgastrectomy symptoms, carcinoma of the gastric remnant should be considered in the differential diagnosis. In a study of 350 asymptomatic patients who were more than 20 years from Billroth II gastric resection, 14 carcinomas were discovered in the region of the stoma. Preoperatively, gross endoscopic appearance and multiple biopsies will usually provide the diagnosis. At the time of revisional surgery, frozen section of gastric biopsies or the resected specimen may be necessary to exclude the diagnosis. At present there is widespread interest in several procedures in the treatment of benign ulcer disease. In selected patients, proximal gastric vagotomy is receiving particular interest. It remains to be determined what, if any, gastric mucosal alterations occur. Since the pyloric mechanism is intact, no stoma is created and no portion of the stomach resected; long-term followup of these patients will be of interest. Information as to the cause of gastric remnant carcinoma can be forthcoming only by evaluation of all groups of patients requiring gastric surgery for benign disease. At the same time, further investigation of patients with gastric carcinoma without prior resection who have atrophic gastritis and intestinal metaplasia is also necessary. The histologic type of carcinoma that develops in the gastric remnant is usually more favorable for surgical cure than those seen in the intact stomach. This means that early diagnosis by radiologic and endoscopic study of postgastrectomy patients developing symptoms is highly desirable. Because of the long interval between gastrectomy and gastric remnant carcinoma these patients are often in the older age group. The location of the lesion in the remaining proximal stomach will nearly always require total gastrectomy. This plus the age factor means that the operative mortality will be rather high. We are unable to explain why in 22 years of observing postgastrectomy patients we have seen only one case of gastric remnant carcinoma. This patient was successfully treated by left transpleural transdiaphragmatic total gastrectomy with Roux-en-Y esophagojejunostomy. This method is particulary easy in the patient who has has an antecolic Billroth II gastrectomy. If the jejunum cannot be adequately mobilized through a radial incision extending laterally from the esophageal hiatus, we use a peripheral diaphragmatic incision in circumferential fashion. This gives excellent exposure of the upper abdominal contents and also preserves the phrenic nerve. As a result, ventilatory function of the left leaf of the diaphragm is preserved postoperatively.

Aged↗
PubMed1999

[Clinical and respiratory function follow-up of 39 infants treated with neonatal respiratory extracorporeal assistance].

UNLABELLED: The aim of this prospective study was to evaluate the consequences of neonatal treatment with a venovenous extracorporeal respiratory assistance. POPULATION AND METHODS: Thirty nine neonates (28 boys) with acute respiratory failure were included. Extracorporeal respiratory assistance consisted of an apnoeic oxygenation with low frequency positive pressure ventilation and extracorporeal membrane CO2 removal through a venous single canula perfusion circuit. The causes of respiratory distress were: 15 meconium aspiration syndrome, 12 respiratory distress syndrome, six hyaline membrane disease, three sepsis, two diaphragmatic hernia, and one post-surgery Mendelson syndrome. The mean duration of mechanical ventilation was 18 days, including 5 days of extracorporeal respiratory assistance. The prospective follow-up included physical examination, chest radiographs, scintigraphy and pulmonary function tests. These tests studied the following parameters: functional residual capacity by helium dilution technique, lung resistance and dynamic lung compliance by the esophageal balloon technique and blood gases with arterialized blood samples. RESULTS: The mean duration of the follow-up was 21.3 months (6 months to 5 years). Results showed in the first year 33% of children with chronic obstructive pulmonary disease and chest (X-ray abnormalities, such as bronchopulmonary dysplasia in 23% of children. Data of pulmonary function test at the end of the first year: lung resistance and functional residual capacity were within limits of predicted values for height, and dynamic lung compliance was slightly decreased; according to the analysis of the functional profile: 31% without abnormality, 41% of obstructive syndrome and 26% with restrictive pattern. Blood gases were normal in 37 children. At the end of the second year, we noticed normal functional residual capacity, an increase of lung resistance while lung compliance was normalized; functional profile was quite different: with a decrease of the number of patients without abnormality (22%) and increase of those with obstructive syndrome (56%). CONCLUSION: The percentage of abnormalities is high but these are moderate in most cases, especially if we compare with the initial seriousness of the pulmonary pathology. We suggest a regular follow-up to study the respective incidence of pulmonary disease and/or extracorporeal respiratory assistance over these abnormalities.

Acute Disease↗
PubMed1990

Urinary tract anomalies associated with congenital diaphragmatic defects.

Anomalies of the urinary tract occur in some 13-27% of infants with congenital posterolateral diaphragmatic defect (CDD) and are often severe (renal agenesis, dysplasia, hypoplasia, or hydronephrosis). To test the hypothesis that urinary and diaphragmatic anomalies share elements of pathogenesis, we reviewed 60 autopsy cases of CDD studied at our institution. Sixteen patients (27%) manifested anomalies of the urinary tract: 12 had markedly altered kidneys, 8 of which were unilateral and ipsilateral to the diaphragmatic defect. Among 27 patients free of gross urinary tract anomalies, kidney weights formed a skewed distribution, with most values above published norms for body weight; by analysis of covariance, kidney weight (as a function of body weight) was significantly greater in CDD than in a control population of infants free of chronic illnesses and congenital anomalies who died suddenly and unexpectedly. Differences in glomerular number and diameter could not be identified between the latter groups. In 71% of patients with isolated left CDD, the left kidney was heavier than the right, a reversal of the usual condition in infancy. These findings demonstrate that both marked and subtle changes of the urinary tract in CDD are generally ipsilateral to the diaphragmatic defect and suggest that the pathogenetic mechanisms responsible for urinary and diaphragmatic anomalies may overlap topographically. Aberrant morphogenesis within a developmental field or fields is one explanation for this.

Abnormalities, Multiple↗
PubMed1997

Malrotation: the postoperative period.

BACKGROUND/PURPOSE: There have been many reports of patients who have persistent gastrointestinal symptoms after undergoing Ladd's procedure. Postoperative return of bowel function in many of these patients seems to be delayed. METHODS: Postoperative return of bowel function after performance of a Ladd's procedure was studied retrospectively in a series of 57 children treated between 1981 and 1994. Excluded were those patients who had a malrotation in combination with an abdominal wall defect, a congenital diaphragmatic hernia, or duodenal atresia. Patients were divided in two groups; one group consisted of patients less than 1 year of age and one group of those 1 year of age and older. RESULTS: Nasogastric tube decompression was necessary for an average of 6.7 days in the first group and 4.3 days in the older children (P = .03). A midgut volvulus delays resumption of bowel function postoperatively. Gastric tube decompression was necessary for 8.6 days (n = 15) compared with only 5.1 days (n = 45) for the group without a volvulus (P = .003, analysis by t test). CONCLUSION: The authors recommend that a central venous line be inserted for feeding purposes when a volvulus is present at operation.

Adolescent↗
PubMed1979

[Posterior gastro-esophago-phreno-plasty (PGEPP) in the treatment of hiatal hernia and of esophagogastric reflux. Experience in over 500 cases. Anterior gastro-esophago-phreno-plasty (AGEPP) in the prevention of sliding hiatal hernia and of esophagogastric reflux. Experience in over 300 cases].

On the basis of the anatomophysiological assumption that the abdominal oesophagus is kept in its seat by the meso-oesophagus and that the complex functional role of the gastro-oesophageal junction is conditioned essentially by the inferior oesophageal sphincter under the influence of intra-abdominal and endogastric pressure variables, posterior gastro-oesophagophreno-plasty (p.g.p.p.) is proposed to offset the destruction or severe insufficiency of the meso-oesophagus and hence for the treatment of hiatal hernia and of regurgitation. This retro-oesophageal tuberous valve involves simultaneous fixation of the stomach and oesophagus to the pillars of the diaphragm, first on the right and then on the left, and the fixation of the fundus to the left diaphragmatic dome. Anterior gastro-oesophago-phreno-plasty is proposed on the basis of the finding that damage of any kind to the meso-oesophagus can cause the oesophagus to rise in the chest and thus disturb inferior sphincter function and possibly lead to the onset of regurgitation and hernia. The pre-oesophageal tuberous valve employed involves simultaneous fixation of stomach and oesophagus to the pillars of the diaphragm, first left and then right, and the fixation of the fundus to the left diaphragmatic dome. Anterior plasty is almost always confined to patients who have undergone vagotomy of the trunk without complex isolation of the oesophagus.

Diaphragm↗
PubMed1983

[Congenital diaphragmatic hernias].

The chances of survival of infants with congenital diaphragmatic hernia have improved only slightly in recent years. Hence, surgery has little to offer towards improvement of prognosis. For this reason, new avenues must be explored which guarantee the functioning of post-foetal circulation and prevent a relapse into the foetal circulation. The emphasis is on continuous registration of the preductal and post-ductal arterial oxygen content, of the pressure conditions in the pulmonary artery and the extent of a right-left shunt. Among the most important therapeutic measures are high-frequency ventilation, effective control of acidosis and the use of vasodilators with pulmonary effectivity. However, their management requires special experience to avoid or control the frequent side effects.

Child↗
PubMed1982

Lung function in infants with congenital pulmonary hypoplasia.

Lung volume and lung mechanics were measured in 19 infants, aged 2 to 8 weeks, with congenital pulmonary hypoplasia of various causes. These included nine infants with congenital diaphragmatic hernia, five infants with Werdnig-Hoffman disease of intrauterine onset, and five infants with isolated pulmonary hypoplasia or associated anomalies such as thoracic dystrophy and spina bifida. Infants were studied within the first two months of life in order to exclude the effects of natural adaptation and adverse influences such as lower respiratory tract infection. Lung volume and airway resistance were estimated by whole body plethysmography, total pulmonary resistance, and dynamic lung compliance with esophageal balloons and pneumotachography. Reductions in dynamic lung compliance were found in seven of the nine infants with congenital diaphragmatic hernia, probably reflecting lung overdistention after operative repair. Low airflow resistance was found in 12 infants, representing subjects from each category. The low airflow resistance may be related to reductions in airway generation number found when the disturbance of lung development occurs before 16 weeks of gestational age. This finding suggests a role for measurements of airflow resistance in characterizing the type of pulmonary hypoplasia.

Airway Resistance↗
PubMed1997

Effect of free radical scavengers on diaphragmatic fatigue.

Recent studies have suggested that free radical scavenger administration reduces the rate of development of diaphragm fatigue. Much of this work has been done, however, using in vitro muscle preparations; the purpose of the present study was to assess the effect of scavengers on in vivo diaphragm contractile function. To accomplish this, we compared the rate of development of fatigue of the electrically stimulated diaphragm in four groups of dogs: (1) animals given intravenous polyethylene glycol adsorbed superoxide dismutase (PEG-SOD, 2,000 units/kg) 1 h before a fatigue trial; (2) a group given intravenous dimethylsulfoxide (DMSO, 0.5 ml/kg of a 50% solution) before fatigue; (3) a group given saline before fatigue; and (4) a group treated with denatured PEG-SOD (2,000 units/kg) before fatigue. We measured diaphragmatic concentrations of thiobarbituric acid reactive substances (TBAR), a marker of free radical-mediated lipid peroxidation, on muscle samples taken at the conclusion of fatigue trials. As a control, we also measured TBAR concentrations for muscle samples taken from nonfatigued diaphragm. We found that the rate of development of diaphragm fatigue was much greater in saline and denatured PEG-SOD-treated groups than for animals pretreated with either PEG-SOD or DMSO, with force falling to 23 +/- 4, 21 +/- 4, 50 +/- 7, and 47 +/- 6% of its initial value, respectively, over a 2-h period of electrophrenic stimulation in these four groups of animals (p < 0.01). TBAR concentrations in fatigued diaphragm from saline and denatured PEG-SOD-treated animals were significantly higher than levels for either nonfatigued fresh diaphragm or fatigued diaphragm taken from PEG-SOD- or DMSO-treated animals (p < 0.01). These data suggest that diaphragm fatigue resulting from repetitive low-frequency stimulation is associated with lipid peroxidation within this muscle and that pretreatment with free radical scavengers prevents lipid peroxidation and reduces the rate of development of fatigue.

Animals↗
PubMed1979

Electromyogram pattern of diaphragmatic fatigue.

We studied the effect of breathing at various levels of transdiaphragmatic pressure (Pdi) on the EMG power spectrum of the diaphragm. The diaphragmatic EMG was measured simultaneously with a bipolar esophageal electrode (EE) and surface electrode (SE) placed on the ventral portion of the sixth and seventh intercostal spaces in five normal subjects breathing at functional residual capacity (FRC) against an inspiratory resistance. During each fatigue run the subjects generated a Pdi, with each inspiration, that was 25, 50, or 75% of maximum Pdi (Pdimax) for a period up to 15 min. During runs at 50 and 75% of the Pdimax, which are known to produce fatigue, we found for both EE and SE a progressive increase in the amplitude of the low-frequency (L = 20-46.7 Hz) and a decrease in the high-frequency (H = 150-350 Hz) component of the EMG. These changes were not seen at 25% of Pdimax. The diaphragmatic H/L ratio was independent of Pdi when the diaphragm was not fatigued. H/L fell while the diaphragm performed fatiguing work and this was more rapid at higher Pdi's. It was thus concluded that frequency spectrum analysis of the EMG can detect diaphragmatic fatigue reliably, prior to the time when the diaphragm fails as a pressure generator.

Diaphragm↗
PubMedDate not supplied

[Gastroesophageal reflux and pulmonary disease].

Gastroesophageal reflux (GER) is a functional entity which is defined as "the involuntary reflux of the gastric contents in the oesophagus, without vomiting and without the involvement of either the gastric, abdominal or diaphragmatic muscles". It is therefore a question of a syndrome which is independent of the anatomical abnormalities in the cardio-tuberositic region (i.e. hiatal hernia). It may also show itself through digestive symptoms, thoracic pains, ENT symptoms and breathing complications. The presence of the latter has been clearly established in certain circumstances: --in infants, GER can cause obstructive apneas, which are responsible for sudden inexplicable deaths (SID): GER and SID have very similar epidemiological characteristics; polygraphic recordings showed that a reflux may immediately precede the onset of obstructive apnea; the instillation of 0.1 N hydrochloric acid in the oesophagus of children with GER causes an apnea. Medical or surgical treatment of the reflux prevents the recurrence of these accidents; --in adults, and older children, GER is responsible for coughs, recurring bronchopneumopathies and asthma; long-term recordings of the oesophageal pH have proved that there is a time-relationship between the two events. Scintigraphic studies have shown the pulmonary contamination by a radioactive isotope placed in the stomach the previous evening. GER has been equally suspected for conditions such as lung abscess, bronchiectasis and hemoptysis, but here it is more difficult to prove. With certain pulmonary fibroses, histological lesions have been compared with those observed during inhalation bronchopneumopathies, but it is difficult to establish a link with a reflux; --functional respiratory studies have not produced a specific functional entity for patients with GER; --careful medical treatment or surgical correction of GER lead to the sedation of respiratory symptoms (RS) in the majority of cases; --the association frequency of a GER and of RS is difficult to establish because of the diversity of the means of diagnosis employed in the past and also because of the heterogeneity of the studied populations, but the frequency is nevertheless high, indeed significantly higher than the prevalence of GER in the general population. The mechanisms which link GER and RS are not well known: first of all, there is the failure of normal antireflux mechanisms and also certain hormonal, alimentary (coffee, alcohol, tobacco, etc.) and therapeutic (theophylline, betamimetics) factors, which facilitate the reflux.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1999

Comparison of venoarterial versus venovenous access in the cerebral circulation of newborns undergoing extracorporeal membrane oxygenation.

This study was designed to compare venoarterial (VA) with venovenous (VV) access in the cerebral circulation of newborn infants during extracorporeal membrane oxygenation (ECMO). Among 14 infants with VA ECMO, 7 had no intracranial complications (group 1), while the others (group 2) developed intracranial hemorrhage (ICH). In contrast, among 19 infants with VV ECMO, only 1 developed ICH. Serial echocardiograms were performed before and after 1, 6, 12, and 24 h and 2 and 3 days of ECMO. The mean cerebral blood flow (CBF) velocities were measured in the anterior cerebral artery (ACA), right and left internal carotid arteries (Rt, Lt-ICA), basilar artery (BA), and right and left middle cerebral arteries (Rt, Lt-MCA). Ejection fraction (EF), cardiac output (CO), and stroke volume (SV) were also measured using standard echography. The velocity levels in the ACA, Rt-MCA, and Lt-MCA in VA ECMO were lower than those in VV ECMO, while those in the Lt-ICA and BA in VA ECMO were higher than those in VV ECMO. The EF, CO, and SV were lower in cases of VA ECMO than in VV ECMO. In cases of VA ECMO, there were no differences between groups 1 and 2 in velocities in the ACA, Rt-ICA, or Lt-ICA. However the velocities in group 2 in the BA, Rt-MCA, and Lt-MCA were lower than those in group 1 before and during ECMO. Similarly, the EF, CO, and SV were lower in group 2 (12.0%-31.0%, 0. 10-0.32 l/min, and 0.66-1.55 ml, respectively) than in group 1 (29. 5%-49.3%, 0.25-0.63 l/min, and 2.15-3.85 ml) during ECMO. However, in the infants on VV ECMO the CBF was either maintained or gradually increased before and during ECMO. Their cardiac parameters were: EF 46.1%-53.0%, CO 0.43-0.52 l/min, and SV 2.72-3.84 ml during ECMO. It is concluded that in VA ECMO CBF velocities, particularly in infants who developed ICH, decreased after the onset of ECMO in association with poor cardiac function, while in VV ECMO they were stable, probably due to normal systemic hemodynamics and cardiac function.

Arteriovenous Shunt, Surgical↗
PubMed1983

Diaphragmatic contractility enhanced by aminophylline: role of extracellular calcium.

We have studied the effects of aminophylline on diaphragmatic contractility in 12 anesthetized dogs. The phrenic nerves were stimulated supramaximally (20 Hz, 0.1 ms) with electrodes placed around the fifth roots, and the transdiaphragmatic pressure (Pdi) generated at functional residual capacity (FRC) was measured with balloon catheters. Constancy of FRC was monitored by measuring the end-expiratory transpulmonary pressure, the dogs being occluded at FRC before the stimulations. The electrical activity of the diaphragm (Edi) during the stimulations was recorded with electrodes inserted in both hemidiaphragms. Phrenic stimulations during an infusion of aminophylline (10 mg/kg in 5 min) increased Pdi by 25 +/- 8% of control values, whereas the Edi remained unchanged. This potentiating effect of aminophylline was abolished when an identical dose was injected during a continuous infusion of a calcium blocker (verapamil, 0.1 mg X kg-1 X min-1). Infusion of another methylxanthine compound, caffeine (10 mg/kg), also increased Pdi for an identical electrical phrenic nerve stimulation by 21 +/- 6% compared with control values. However, the potentiating effect of caffeine was not abolished by verapamil. We conclude that aminophylline in vivo increases diaphragmatic contractility and that extracellular calcium is necessary for this action, a mechanism not shared by another methylxanthine compound, caffeine.

Aminophylline↗