The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry

OBJECTIVES

Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome.

STUDY DESIGN

Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis (EEA)/tracheoesophageal fistula (TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates.

RESULTS

Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups.

CONCLUSION

We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

Living With My Baby With Congenital Anomaly: A Qualitative Case Report

This case report was made to understand the emotions, thoughts, and experiences of the mother, who was lying in the long-term neonatal intensive care unit. An individual in-depth interview was conducted once with the mother of the infant with the diaphragm hernia. The interview recorded and lasted approximately 30 min. The data were analyzed by inductive method and themes and codes were created. The mother of the infant with a diaphragmatic hernia was 31 years old, married with 2 children, and employed full-time. The infant was diagnosed antenatally at 37 weeks old, weighed 3.000 g, and was male. As a result of the interview, 3 main themes were identified: “Facing the disease,” “Experiences in intensive care,” and “Change in family life.” The results show that having an infant with congenital anomaly affects the life of all family members and shows the problems experienced strikingly.

Pulmonary Metastasectomy of Sarcoma: Is the Ratio of Surgical Margin to Nodule Size a Prognostic Factor?

BACKGROUND

 Main prognostic factors of improved survival after pulmonary metastasectomy (PM) for osteogenic and soft tissue sarcomas are suggested as histological type, number and size of pulmonary nodules, and disease-free interval (DFI).

METHODS

 Sixty-nine patients who underwent PM between January 1999 and December 2017 were evaluated retrospectively. Relations between parameters and prognostic risk factors for overall survival (OS) and disease-free survival (DFS) were evaluated.

RESULTS

 Osteosarcoma was the most common histologic type (36.2%) and 21 of 25 cases were seen under the age 20 years (p < 0.001). Comparison of patient groups including osteosarcoma and nonosteosarcoma patients showed significant difference according to age (p < 0.001), nodule size (p = 0.033), ratio of surgical margin to nodule size (p = 0.007), and DFI (p = 0.039). Univariate analysis showed that the number of nodules (p = 0.008), ratio of surgical margin to nodule size (p = 0.001), and localization of nodule (p = 0.039) were significant factors associated with DFS. Also, nodule size (p = 0.042), number of nodules (p = 0.003), ratio of surgical margin to nodule size (p < 0.001), and laterality (p = 0.027) were significant prognostic factors associated with OS. Cut-off values of ratio of surgical margin to nodule size for DFS and OS were calculated as 0.94. Logistic regression analysis determined the ratio of surgical margin to nodule size as the common significant risk factor for DFS and OS.

CONCLUSIONS

 Our study showed that the ratio of surgical margin to nodule size ≥ 1 should be taken as a common risk factor for DFS and OS. Therefore, resection of nodules with the possible widest surgical margin is an important point of PM.

Oncocytic Adreno Cortical Tumors: Pathological Features of 16 Cases and Review of the Literature

Oncocytic neoplasms of the adrenal gland are extremely rare tumors. These tumors differ from their nononcocytic counterparts in some respects. The aim of this study was to review and discuss the clinical, histological, and immunohistochemical features of as well as the prognosis for these rare tumors. In total, 16 cases diagnosed as adrenocortical oncocytic neoplasms between January 2011 and December 2016 were included in the study. The demographic data, gross characteristics, histological data, and immunohistochemical data (Chromogranin-A, Synaptophysin, α-Inhibin, Melan-A, Ki67, PHH3) were reevaluated. The follow-up data for these patients were added in January 2017. Of the 16 cases, 12 were adrenocortical adenoma, 1 was borderline adrenocortical tumor, and 3 were adrenocortical carcinoma. The tumors equally affected both genders. The tumors were not generally large. Tumor cells had pleomorphic nuclei in ten cases, but it was more obvious in one case. The mitotic figure count was low in most tumors. Atypical mitosis and necrosis were observed in three and four tumors, respectively. None of cases included sinusoidal invasion, vascular invasion, or capsular invasion. We detected the expression of at least one specific marker (e.g., Melan-A, Inhibin-α) of the adrenal cortex in all tumors. None of the tumors were immunoreactive for Chromogranin-A. Ki-67 proliferation index was lower than 5% in all cases except three oncocytic carcinomas. In two cases, PHH3 positivity was not seen, while it was lower than 3 of 10 high-powered fields in ten cases and higher in 4 cases. All patients were alive and disease free except for two patients with adrenocortical carcinoma. In conclusion, determining the clinical, histological, and immunohistochemical characteristics of these extremely rare tumors can provide important information for early diagnosis, treatment, and follow-up of these cases.

Radiological nodule behavior: A critical parameter in the surgical management of pediatric pulmonary metastases

Divarcı E, Arslan S, Dökümcü Z, Kantar M, Demirağ B, Öniz H, Ertan Y, Alper H, Erdener A, Özcan C. Radiological nodule behavior: A critical parameter in the surgical management of pediatric pulmonary metastases. Turk J Pediatr 2018; 60: 372-379. Radiological nodule behavior (RNB) means the course of nodule appearance on consecutive CT scans. In this study, we aimed to discuss the effects of RNB on prognosis of patients with pulmonary metastasis. Retrospective analysis of patients who underwent pulmonary metastasectomy (PM) between 2005-2015 was performed. RNBs were grouped as stable, enlarging or new rising nodules. The effects of RNBs were analyzed on recurrence, 1- and 3-year event free survival (EFS) and mortality. Twenty-seven patients (18 male) underwent PM with a median age of 15 years (3-18 years). The diagnoses were listed as osteosarcoma (13), Wilms` tumor (7), Ewing`s sarcoma (3), synovial sarcoma (2), rabdomyosarcoma (1) and mixed germ cell tumor of testis (1). RNBs were new rising in 15 patients (55%), enlarging in seven patients (26%) and stable in five patients (19%). Vital tumor metastasis was detected in all of the patients with enlarging nodules (100%); in 10 of the 15 patients with new rising nodules (66%) and none of the patients with stable nodules. None of the patients with stable nodules developed recurrence or died after PM (p˂0.05). In patients with enlarging nodules, metastases recurred and they died in the postoperative period. These findings were similar in different types of tumors. RNB could be used as a critical parameter in deciding surgical management strategies of pulmonary metastases. Stabile nodules should be observed by close follow-up with serial CT scans without surgery. All of the suspected new rising nodules should undergo surgical sampling to avoid unnecessary chemotherapy. Nodule progression under chemotherapy is a poor prognostic criteria for overall survival.

Management of Childhood Thyroid Nodules: Surgical and Endocrinological Findings in a Large Group of Cases

OBJECTIVE

The management of childhood thyroid nodules is still a big challenge for clinicians. In this study, we aimed to present our surgical and endocrinological experience in more than one hundred pediatric cases.

METHODS

A retrospective analysis of patients admitted with a thyroid nodule between 2006 and 2014 was performed. Detailed ultrasonography and fine-needle aspiration biopsy (FNAB) were the cornerstones of the diagnostic approach.

RESULTS

One hundred-three children (72 female, 31 male) with a mean age of 13.1±3.6 years (3-18 years) were admitted to our center. Management strategy was surgery in 58 patients and follow-up in 45 patients. Mean nodule size was 17±12.7 mm (2-45 mm). The diagnoses were listed as benign solitary nodule (48 patients), thyroid carcinoma (26 patients), multinodular goiter (23 patients), Hashimoto thyroiditis (4 patients), and Graves' disease (2 patients). Surgical procedures were nodulectomy/lobectomy (32 patients), total thyroidectomy (TT) (13 patients), or TT+ neck dissection (13 patients). The rate of malignancy was 25% in the total group and 44% in the surgery group. The malignancy rate was higher in patients younger than 12 years compared to older children (41% vs. 17%, p=0.040). Metastasis was seen in 38% of the malignant nodules. Postoperative complications were transient hypocalcemia (8%), permanent hypocalcemia (1.7%), and unilateral vocal cord paralysis (1.7%). Recurrence or mortality was not encountered in the 5.4±1.2-year follow-up period.

CONCLUSION

Thyroid nodule in a child requires an aggressive diagnostic approach due to increased risk of malignancy and metastasis. Intraoperative frozen section examination must be done as a useful adjunct to determine the surgical strategy. Incidence of complications is small in thyroid surgery when performed by experienced surgeons.

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation

ADH following OLT is a rare entity. Herein, we report a case of Alagille syndrome who developed ADH secondary to OLT, and possible etiological causes are discussed in light of the literature.

Intraoperative parathyroid hormone monitoring corroborates the success of parathyroidectomy in children

OBJECTIVE

To assess the efficacy of intraoperative parathyroid hormone (PTH) monitoring in evaluating the outcome of parathyroidectomy in pediatric patients.

METHODS

Intraoperative PTH monitoring during parathyroidectomy was performed in five children (3M, 2F); three had parathyroid adenomas (single gland disease) and two had primary hyperplasia. One patient had undergone two previous surgical interventions to remove the parathyroid glands, but the PTH levels had remained high with persistence of symptoms. Immunoradiometric analysis was used for PTH measurements. Preoperative PTH values were obtained to monitor the baseline levels. Serum samples were collected 20 minutes after removal of the adenoma/parathyroid gland(s) and PTH levels were compared with preoperative values. Specimens were also confirmed by frozen sectional examination.

RESULTS

Mean age of the patients was 11 years (range: 3 months-16 years). Mean preoperative PTH values were 633.3±579 pg/mL (range: 143-1300 pg/mL). Intraoperative values decreased to 18.7±5.5 pg/mL (range: 8-27 pg/mL) following removal of the gland(s). Normal calcium levels were achieved with adequate management following surgery. One patient (with multiple surgeries and found to have an ectopic parathyroid gland) had hungry bone syndrome after the operation and was treated successfully. There were no major complications. All patients maintained normal calcium/phosphorus levels in the follow-up period, ranging from 2 to 5 years.

CONCLUSION

An ectopic parathyroid gland or another undetected adenoma can be overlooked during surgery. Owing to the short life of the hormone, intraoperative PTH monitoring to determine PTH clearance proved to be a feasible marker for adequacy and safety of surgery and "cure".

Protective effects of hyperbaric oxygen and iloprost on ischemia/reperfusion-induced lung injury in a rabbit model

Background

The role of multiorgan damage in the mortality caused by ischemic limb injury is still not clarified. The objective of this study was to examine the potential protective effects of hyperbaric oxygen (HBO) and iloprost (IL) therapy on lung damage induced by limb ischemia/reperfusion injury in a rabbit model, using both biochemical and histopathological aspects.

Methods

Forty New Zealand white rabbits were randomly allocated into one of five study groups: HBO group (single session of HBO treatment); IL group (25 ng/kg/min infusion of IL); HBO + IL group (both HBO and IL); Control group (0.9% saline only); and a sham group. Acute hind limb ischemia-reperfusion was established by clamping the abdominal aorta for 1 h. HBO treatment and IL infusion were administrated during 60 min of ischemia and 60 min of reperfusion period. Blood pH, partial pressure of oxygen, partial pressure of carbon dioxide and levels of bicarbonate, sodium, potassium, creatine kinase, lactate dehydrogenase, and tumor necrosis factor alpha were determined at the end of the reperfusion period. Malondialdehyde was measured in the plasma and lung as an indicator of free radicals. After sacrifice, left lungs were removed and histopathological examination determined the degree of lung injury.

Results

In the control group, blood partial pressure of oxygen and bicarbonate levels were significantly lower and creatine kinase, lactate dehydrogenase, malondialdehyde and tumor necrosis factor-α levels were significantly higher than those of the HBO group, IL group, HBO + IL group and sham group. Similarly, the malondialdehyde levels in the lung tissue and plasma levels were significantly lower in the treatment groups compared with the control group. The extent of lung injury according to the histological findings was significantly higher in the control group.

Conclusions

These results suggest that both HBO and IL therapies and their combination might be effectively used in the prevention of lung injury after ischemia/reperfusion injury of the lower extremities.

Sliding appendiceal inguinal hernia: preoperative sonographic diagnosis

We report the case of a 3-month-old boy with a right-sided sliding appendiceal inguinal hernia that was diagnosed preoperatively with sonography. Surgery was performed, and intraoperative and histopathologic evaluations also revealed changes in the appendix that could have led to complications if left untreated. The infant's recovery was uneventful, and he was discharged on the second day after surgery. This condition is usually diagnosed intraoperatively, and to the best of our knowledge, this is only the second report in the English-language medical literature in which such a case was correctly diagnosed preoperatively with sonography. In our case, the early sonographic diagnosis led to early intervention and the avoidance of potential complications.

Submucosal pressure-air insufflation facilitates endorectal mucosectomy in transanal endorectal pull-through procedure in patients with Hirschsprung's disease

BACKGROUND

Most children with Hirschsprung's disease (HD) can be treated with a transanal endorectal pull-through (TEP) procedure. The authors have developed a simple technique of submucosal pressure-air insufflation (SI) to facilitate the submucosal dissection, which is one of the crucial parts of the operation.

METHODS

Six patients with HD were treated by using TEP in one year. After adequate positioning and exposure, anal mucosa was incised 1 cm above the dentate line, and 4-quadrant SI with a simple system of scalp-vein needle connected to a 20-mL syringe was used in all of the patients. Submucosal proctectomy, aganglionic and dilated segment colectomy, and coloanal anastomosis were completed transanally, but, in 2 of the patients, laparoscopic assistance to release the colon was required.

RESULTS

There were no intraoperative and postoperative complications related to SI. Submucosal dissections were completed smoothly in all of the patients with negligible amount of bleeding. The only complication during the submucosal dissection was mucosal perforation at the site of previous rectal biopsy in 2 patients. Average operating time was 2.7 hours (range, 90-180 min), and mean length of resected bowel was 22.5 cm (range, 12 to 42 cm). Follow-up is 8 to 14 months. Frequent bowel movements (>8 times per day) and perianal dermatitis were observed in 2 patients but returned to acceptable limits in 3 months. One patient had to undergo reoperation for adhesive intestinal obstruction.

CONCLUSIONS

SI is simple, and offers a safe and faster dissection with minimum amount of bleeding during the endorectal mucosectomy in TEP procedure.