Review and discussion of the complications of minimally invasive pectus excavatum repair

PURPOSE

To review and discuss the complications of minimally invasive pectus excavatum repair.

METHODS

329 patients underwent minimally invasive pectus repair between January 1987 and August 2000, including 14 patients who recurred after previous Ravitch repairs, 10 failed Nuss repairs (eight done elsewhere) and two failed Leonard repairs. All patients received antibiotics and vigorous incentive spirometry to prevent atelectasis, pneumonia and bar infection. Epidural anesthesia was used for postoperative analgesia to keep patients comfortable and stable postoperatively and to prevent bar displacement. Thoracoscopy was used during bar insertion to minimize the risk of mediastinal injury and to select the best position for the bar. A new introducer was developed to elevate the sternum before bar insertion. A stabilizing bar was created to minimize bar displacement. The duration of sternal bracing has been increased from two years to three or four years in selected patients.

COMPLICATIONS

There were no deaths, no cardiac perforations and no cases of thoracic chondrodystrophy. Pneumothorax with spontaneous resolution occurred in 52 % of the patients, with 1.2 % requiring simple aspiration and 1.5 % requiring chest tube drainage. This complication has essentially been eliminated by using a "water seal system". Pericarditis occurred in 2.4 % with good response to Indomethacin in six out of eight patients and two patients also required pericardial fluid aspiration. Pneumonia occurred in 0.9 %. Wound infection occurred in 2.6 % resulting in bar infection in three out of the seven patients. Long-term antibiotics were successful in curing the infection in one patient, whereas the other two required bar removal at 12 and 18 months, respectively. Bar displacement occurred in 8.8 % of patients. However, the introduction of stabilizers decreased the incidence from 15.7 % before the use of stabilizers to 5.4 % with stabilizers. Wiring the bar and stabilizer together has decreased the incidence even further.

RESULTS

Long-term outcome after bar removal showed an excellent result in 71 %, good result in 21 % and recurrence in 7.8 %.

CONCLUSION

The minimally invasive technique has a low complication rate with excellent long-term results.

The Nuss procedure for pectus excavatum correction

Pectus excavatum is an anterior chest wall deformity that now can be corrected with a minimally invasive technique known as the Nuss procedure. Patient criteria and assessment for this new surgical procedure are defined clearly in advance to ensure the need for surgical intervention. A multidisciplinary team approach has been established at Children's Hospital of The King's Daughters, Norfolk, Va. Team members work cooperatively throughout the perioperative cycle, addressing not only the surgical procedure but also pain management and postoperative recovery. This dedicated team approach helps ensure a successful outcome for the patient.

Radiologic considerations in patients undergoing the Nuss procedure for correction of pectus excavatum

The Nuss procedure has succeeded in minimizing incisions, blood loss, sternal fracturing, operating room time, recovery time, and length of hospital stay. Knowledge of the pre- and postoperative radiologic considerations is essential in providing appropriate imaging support to the surgeons performing this innovative, minimally invasive procedure.

The effects of a pediatric unilateral inguinal hernia clinical pathway on quality and cost

BACKGROUND/PURPOSE

The purpose of this study is to discover whether a pediatric inguinal hernia surgical clinical pathway (CP) reduces the frequency of wound infections, return visits, times associated with surgical repair, or costs.

METHODS

A multidisciplinary team developed the inguinal hernia surgical clinical pathway. Healthy children greater than 50 weeks gestational age who required unilateral hernia repair were considered for the study. Two groups were formed: (1) an intervention group selected randomly (n = 46, CI = 95%, power = .80) from patients enrolled from November 1996 through April 1997, and (2) a retrospective cohort control group (n = 46) matched to each intervention patient by age, gender, and medical history. Analysis of variance and chi2 testing were used to test for significant differences between the 2 groups in postoperative wound infections, readmission and emergency department return visits within 72 hours, times associated with surgical repair, and costs.

RESULTS

There were no significant differences in postoperative wound infections, times associated with surgical repair, or readmission rates within 72 hours. Total cost significantly decreased, by 10% (P< or = .05), for pathway patients ($982 v $880).

CONCLUSION

These results show that the use of a pediatric inguinal hernia surgical clinical pathway is associated with reduced cost while maintaining quality of care.

Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases

BACKGROUND/PURPOSE

Since the first report in 1997 by Dr Nuss of the technique for minimally invasive repair of pectus excavatum (MIRPE), the popularity and demand for this operation has increased dramatically. Many pediatric surgeons became familiarized with MIRPE and have applied it to a large number of patients. Outcomes and complications have not yet been defined.

METHODS

A comprehensive survey of APSA members was conducted to review technical problems, complications, and outcomes of this new technique.

RESULTS

Of the 74 survey responders, 31 (42%) currently use the MIRPE as their procedure of choice, and 251 cases were reviewed. A total of 74.2% of surgeons relied on direct observation and written documentation to obtain training in MIRPE. Less than 60% used the chest index in the preoperative assessment. A total of 98% used the Walter Lorenz bar for the MIRPE. The most common complication was bar displacement or rotation requiring reoperation (9.2%). Pneumothorax requiring tube thoracostomy was reported in 4.8%. Less common problems included infectious complications (2%), pleural effusion (2%), thoracic outlet obstruction (0.8%), cardiac injury (0.4%), sternal erosion (0.4%), pericarditis (0.4%), and anterior thoracic artery pseudoaneurysm (0.4%). Three patients (1.2%) required early strut removal. Reoperation using the open modified Ravitch approach was performed in 2 patients (0.8%). Most surgeons indicated that teenaged patients (>15 years old) were at higher risk for complications. Thoracoscopy in combination with MIRPE was used by 61% of the surgeons. Overall patient satisfaction was rated as excellent or good (96.5%).

CONCLUSIONS

The relatively high incidence of problems with MIRPE is probably related to the learning curve associated with the introduction of this new technique. Awareness of technical details, careful patient selection, use of a stabilizing bar, and thoracoscopy likely will result in decreased complications. Long-term results are yet to be determined. The development of a national registry is of great importance for further outcome analysis of MIRPE.

Initial assessment of gene diversity for the oomycete pathogen Phytophthora infestans based on expressed sequences

A total of 1000 expressed sequence tags (ESTs) corresponding to 760 unique sequence sets were identified using random sequencing of clones from a cDNA library constructed from mycelial RNA of Phytophthora infestans. A number of software programs, represented by a relational database and an analysis pipeline, were developed for the automated analysis and storage of the EST sequence data. A set of 419 nonredundant sequences, which correspond to a total of 632 ESTs (63.2%), were identified as showing significant matches to sequences deposited in public databases. A putative cellular identity and role was assigned to all 419 sequences. All major functional categories were represented by at least several ESTs. Four novel cDNAs containing sequences related to elicitins, a family of structurally related proteins that induce the hypersensitive response and condition avirulence of P. infestans on Nicotiana plants, were among the most notable genes identified. Two of these elicitin-like cDNAs were among the most abundant cDNAs examined. The set also contained several ESTs with high sequence similarity to unique plant genes.

A 10-year review of a minimally invasive technique for the correction of pectus excavatum

PURPOSE

The aim of this study was to assess the results of a 10-year experience with a minimally invasive operation that requires neither cartilage incision nor resection for correction of pectus excavatum.

METHODS

From 1987 to 1996, 148 patients were evaluated for chest wall deformity. Fifty of 127 patients suffering from pectus excavatum were selected for surgical correction. Eight older patients underwent the Ravitch procedure, and 42 patients under age 15 were treated by the minimally invasive technique. A convex steel bar is inserted under the sternum through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. After 2 years, when permanent remolding has occurred, the bar is removed in an outpatient procedure.

RESULTS

Of 42 patients who had the minimally invasive procedure, 30 have undergone bar removal. Initial excellent results were maintained in 22, good results in four, fair in two, and poor in two, with mean follow-up since surgery of 4.6 years (range, 1 to 9.2 years). Mean follow-up since bar removal is 2.8 years (range, 6 months to 7 years). Average blood loss was 15 mL. Average length of hospital stay was 4.3 days. Patients returned to full activity after 1 month. Complications were pneumothorax in four patients, requiring thoracostomy in one patient; superficial wound infection in one patient; and displacement of the steel bar requiring revision in two patients. The fair and poor results occurred early in the series because (1) the bar was too soft (three patients), (2) the sternum was too soft in one of the patients with Marfan's syndrome, and (3) in one patient with complex thoracic anomalies, the bar was removed too soon.

CONCLUSIONS

This minimally invasive technique, which requires neither cartilage incision nor resection, is effective. Since increasing the strength of the steel bar and inserting two bars where necessary, we have had excellent long-term results. The upper limits of age for this procedure require further evaluation.

Growth patterns, ultrastructure, and chromosomal constitution of normal kidney and nephroblastoma cells in short-term culture

Nephrectomies were performed on four children with nephroblastomas (Wilms' tumor). Tumor tissue and normal kidney tissue were taken from each patient and were cultured. The in vitro characteristics of the cultured cells were then compared with their known in vivo characteristics. The normal kidney cells showed uniform cell morphology, had a relatively slow and orderly growth pattern and had the usual diploid chromosomal constitution. The tumor cells on the other hand were irregular in morphology and had a rapid and disorderly growth pattern. Electron microscopic examination confirmed the variation in the tumor cell morphology. In addition, microfilaments were seen to be abnormally abundant in many of the cells and some cells contained membrane-bound granules. Desmosomes were absent. Chromosome analyses showed cells from three of the nephroblastoma samples to maintain a constant hyperdiploid karyotype during the first few passages in vitro, whereas the normal kidney cells continued to have the normal diploid karyotype. Our study suggests that nephroblastoma and normal kidney cells are stable in culture, that is they retain most of their cellular characteristics in vitro and do not undergo rapid dedifferentitation in short-term culture.

Successful management of oesophageal atresia type IIIa by oesophageal stretching: a case report

A case of oesophageal atresia type IIIa and anorectal agenesis is presented, in which stretching of the oesophagus resulted in successful delayed oesophageal anastomosis, thereby avoiding the need for colonic oesophageal replacement and thus greatly facilitating the repair of the anorectal agenesis. The literature is reviewed and it is concluded that every attempt should be made to effect oesophageal anastomosis, because the colon interposition procedure carries not only a high early mortality but also a high late complication rate.

Late-onset intestinal obstruction in cystic fibrosis--meconium ileus equivalent

Four patients who suffered from cystic fibrosis and late-onset bowel obstruction (meconium ileus equivalent), and who were treated by surgery, are discussed. The importance of early correct diagnosis is stressed, since surgery may be prevented if bowel washouts and oral medications are given before the condition becomes complicated.

Cultural characteristics of mesoblastic nephromas

Seven infants and children with renal tumors underwent nephrectomy and the tumors were cultured to investigate the behavior of their cells. In four children over 1 year of age with histologically typical nephroblastoma in the tumor cells were bizarre and disorderly. In one patient 3 months of age where the histology suggested malignancy the tumor culture showed an orderly growth pattern of spindle cells akin to normal kidney and the patient has had no recurrence for 18 months. In one infant seven months of age the histology was consistent with malignancy and this was confirmed on culture showing bizarre cells similar to those of nephroblastoma. The third infant under 1 year of age had a teratoma on histology and an unusual growth pattern on culture characterised by polyhedral cells with long processes and much overlapping. It is suggested that in infants with kidney tumors, tissue culture be used to help in assessing the malignant potential of the tumor and deciding on adjuvant therapy.

Biliary atresia in a twin

The occurrence of biliary atresia in one of a pair of male twins is reported. The current concepts regarding the aetiology of biliary atresia are examined in relation to this case; and neither the concept of a transplacental agent nor that of a genetic trigger mechanism seems probable. It is concluded that, as with many congenital defects, biliary atresia is probably the end-result of different aetiological factors, among which viruses and other agents may cross the placenta to cause it, whether or not there is a genetic predisposition in the individual fetus, or the biliary system may simply fail to develop.

The management of hernias, hydroceles and undescended testes

The management of hernias, hydroceles and undescended testicles is reviewed on the basis of current practice as reported in recent literature and of the author's experience at Addington Hospital, Durban.

Control of peptide chain initiation in uninfected and virus infected cells by membrane mediated events

Initiation of protein synthesis in tissue culture cells is rapidly inhibited or blocked by addition of either DMSO, ethanol, TPCK, cytochalasin B, or sucrose to the growth medium. In contrast, these agents do not interfere with the initiation of protein synthesis in cell-free extracts to a comparable extent. These results support the hypothesis that protein synthesis in tissue culture cells can be influenced by membrane mediated events. Translation of viral mRNA in RNA virus infected cells is resistant to a number of these inhibitors of peptide chain initiation and proceeds under conditions where translation of host mRNA is almost completely suppressed. It appears that viral mRNA possesses a greater ability than host mRNA to form mRNA-ribosome initiation complexes when the overall rate of peptide chain initiation is reduced. This observation has led to a number of predictions concerning the strategy of virus directed suppression of host mRNA translation. Under optimal growth conditions protein synthesis appears to be regulated mainly, but not exclusively, by the amount of the mRNA available for translation. However, when cellular growth and/or the overall rate of peptide chain initiation is restricted, control of protein synthesis at the translational level becomes decisive with the translation of each mRNA species proceeding with its own characteristic efficiency most probably as a result of inherent differential affinities of individual mRNA species for ribosomes.