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Abstract
Tracheal bronchus (TB) occurs in 0.1-3% of the population as an accessory bronchus that originates in the trachea, typically supplying the right upper lobe. The presence of a TB can pose unique airway challenges, particularly during procedures that require lung isolation. Here, we describe a case of TB with difficult lung isolation. Careful examination with fiberoptic bronchoscopy permitted double lumen tube positioning without obstruction of the TB. A second case is presented where the presence of TB did not affect anesthetic management. Implications of TB for airway management and strategies for successful one-lung ventilation are discussed.
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Affiliation(s)
- Daniel A Friedlander
- Department of Anesthesiology, 21654University of Connecticut School of Medicine, Farmington, CT, USA
| | - Rabi Panigrahi
- Department of Anesthesiology, 21654University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Anesthesiology, 23893Hartford Hospital, Hartford, CT, USA
| | - Dhamodaran Palaniappan
- Department of Anesthesiology, 21654University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Anesthesiology, 23893Hartford Hospital, Hartford, CT, USA
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Benz KS, Jayman J, Maruf M, Baumgartner T, Kasprenski MC, Friedlander DA, Di Carlo HN, Sponseller PD, Gearhart JP. Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children. J Pediatr Surg 2018; 53:2160-2163. [PMID: 29370895 DOI: 10.1016/j.jpedsurg.2017.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/18/2017] [Accepted: 11/27/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. METHODS The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. RESULTS Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059). CONCLUSION Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years). LEVEL OF EVIDENCE Level III, Retrospective comparative study STUDY TYPE: Therapeutic study.
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Affiliation(s)
- Karl S Benz
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John Jayman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Timothy Baumgartner
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Matthew C Kasprenski
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Daniel A Friedlander
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Heather N Di Carlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
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Abstract
INTRODUCTION Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. OBJECTIVE To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. STUDY DESIGN Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. RESULTS A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. DISCUSSION This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. CONCLUSION Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.
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Affiliation(s)
- D A Friedlander
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - W W Ludwig
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J R Jayman
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Akhavan
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Friedlander DA, Di Carlo HN, Sponseller PD, Gearhart JP. Complications of bladder closure in cloacal exstrophy: Do osteotomy and reoperative closure factor in? J Pediatr Surg 2017; 52:1836-1841. [PMID: 27989536 DOI: 10.1016/j.jpedsurg.2016.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/01/2016] [Accepted: 12/03/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The aims of surgical management in cloacal exstrophy (CE) have shifted to optimizing outcomes and quality of life while minimizing morbidity. This report reviews the single-institution experience of complications of bladder closure in CE. METHODS Patients with CE were identified from a prospectively-maintained bladder exstrophy-epispadias complex database. Operative and follow-up data were analyzed to compare complications and failure rates of bladder closure between closures performed with and without osteotomy and primary versus reoperative closures. RESULTS Of 134 patients followed with CE, 112 met inclusion criteria. Median follow-up time was 3.05years. The failure rate among 112 primary closures (mean age 8.4months) was 31.3% versus 51.9% in reoperative closures (mean age 19.7months) (p=0.044). Complication rate among primary and reoperative closures was 17.9% and 33.3%, respectively (p=0.076). For closures with pelvic osteotomy, failure rate was 24.0% versus 45.9% without osteotomy (p=0.018). Among primary closures with osteotomy, the complication rate was 21.3% versus 10.8% without osteotomy (p=0.171). CONCLUSIONS Complications of bladder closure are common in CE. Pelvic osteotomy reduces failure rates without a significant rise in complications, which are often minor. There was no statistically significant difference in complication rates between reoperative and primary closures. However, reoperative closures were more likely to fail, emphasizing the importance of a successful primary closure. LEVEL OF EVIDENCE II: retrospective study.
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Affiliation(s)
- Daniel A Friedlander
- Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Heather N Di Carlo
- Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Paul D Sponseller
- Division of Pediatric Orthopaedics, Department of Orthopaedics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John P Gearhart
- Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Friedlander DA, Lue KM, Michaud JE, Gearhart JP, Redett RJ, Di Carlo HN. Repair of Vesicocutaneous and Urethrocutaneous Fistulae with Rectus Muscle Flap in a Bladder Exstrophy Patient. Urol Case Rep 2017; 13:42-44. [PMID: 28443240 PMCID: PMC5397601 DOI: 10.1016/j.eucr.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/24/2022] Open
Abstract
Urinary continence can be achieved in up to 90% of patients with bladder exstrophy. However, select patients remain incontinent despite modern reconstruction. Repeat operations for continence combined with the congenital pelvic abnormalities of exstrophy put patients at risk for urinary fistula formation. We report the use of a rectus muscle flap in the repair of two concomitant vesicocutaneous and urethrocutaneous fistulae in a patient with classic bladder exstrophy.
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Affiliation(s)
- Daniel A Friedlander
- Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathy M Lue
- Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason E Michaud
- Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Gearhart
- Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heather N Di Carlo
- Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sirisreetreerux P, Lue KM, Ingviya T, Friedlander DA, Di Carlo HN, Sponseller PD, Gearhart JP. Failed Primary Bladder Exstrophy Closure with Osteotomy: Multivariable Analysis of a 25-Year Experience. J Urol 2017; 197:1138-1143. [DOI: 10.1016/j.juro.2016.09.114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Pokket Sirisreetreerux
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathy M. Lue
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thammasin Ingviya
- Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A. Friedlander
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heather N. Di Carlo
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul D. Sponseller
- Division of Pediatric Orthopaedics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John P. Gearhart
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Friedlander DA. The changing face of dentistry. J Can Dent Assoc 1999; 65:144-5. [PMID: 10202411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Abstract
OBJECTIVES The purpose of this descriptive analysis is to demonstrate that among older patients with hyponatremia, there is a subset with apparent hyponatremia of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) type, which appears associated with the aging process. A retrospective chart review was done to identify patients with hyponatremia and to classify them into non-SIADH, SIADH, and idiopathic categories. DESIGN The participants were the ambulatory population of The Mount Sinai Hospital's outpatient geriatric clinic. Pertinent data generated during the antecedent 24 months were collected from outpatient charts and included sets of laboratory values (consisting of one sodium, glucose, BUN and creatinine level), age, sex, race, clinical history, present diagnosis, medications, and prescribed diets for each patient in the total population. RESULTS Patients demonstrating hyponatremia with serum sodium levels of less than 135 mEq/L were identified from the total population and were further divided into SIADH and non-SIADH etiologies. The SIADH patients were then subdivided into known etiology SIADH and apparent idiopathic SIADH. In an ambulatory geriatric population of 405 subjects, 46 had hyponatremia, with SIADH the apparent cause in 27. Of the SIADH population, seven patients were considered to have idiopathic SIADH. An apparent predilection for development of this syndrome was observed among non-black patients and the old old. CONCLUSIONS The results support the hypothesis that aging is a risk factor for the development of SIADH-like hyponatremia in a subset of older patients who do not have an apparent underlying etiology. Thus, aging may be an independent etiology for the development of hyponatremia.
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Affiliation(s)
- M Miller
- Department of Geriatrics and Adult Development, The Mount Sinai Medical Center, New York, NY 10029, USA
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