High frequency oscillatory ventilation and extracorporeal membrane oxygenation in severe persistent pulmonary hypertension of the newborn

We report on 50 term and near-term neonates (birth weight greater than 1800 g, gestational age greater than 33 weeks) with severe persistent pulmonary hypertension of the newborn (PPHN), referred to us from January 1987 to July 1991 after failure of maximum conventional treatment. All infants had paO2 less than 45 mm Hg when ventilated with peak inspiratory pressure greater than 38 cm H2O and FiO2 = 1.0, hence meeting entry criteria for extracorporeal membrane oxygenation (ECMO). High frequency oscillatory ventilation (HFOV) was tried in all patients. If sufficient oxygenation could not be achieved (paO2 less than 40 mm Hg for at least 2 h), ECMO therapy was begun, which was the case in 25 children. Neonates responding to HFOV (n = 25) were of a slightly younger gestational age (37.0 weeks vs 38.8 weeks, P less than 0.05), had higher Apgar scores and were less hypoxaemic before HFOV (paO2 36.6 mm Hg vs 28.8 mm Hg, P less than 0.01); during HFOV there was a significant rise in paO2 (greater than 150 mm Hg; P less than 0.001) and a fall in pCO2 to 21.6 mm Hg (P less than 0.001). Due to air leaks, which was the main complication of HFOV (52%), ECMO therapy had to be begun in two additional infants after an initial positive effect. HFOV tended to be successful in cases of primary PPHN, meconium aspiration and sepsis, but not in infants with lung hypoplasia as a result of diaphragmatic hernia or other reasons. Success or failure of HFOV could not be reliably predicted by any parameter.(ABSTRACT TRUNCATED AT 250 WORDS)

Indication for using extracorporeal membrane oxygenation in congenital diaphragmatic hernias and pulmonary hypoplasia

Despite the apparent surgical simplicity of the anatomic defect, congenital diaphragmatic hernia continues to be a critical problem in neonatal surgery, so that survival is still uncertain. Therefore, we must realize that the barriers to survival are pulmonary parenchymal and vascular hypoplasia as well as the complex syndrome of persisting fetal circulation. However, new treatment methods, such as extracorporeal membrane oxygenation (ECMO), although controversial, may improve survival. We believe that no infant should be excluded from diaphragmatic repair or consideration for ECMO-support before accurate predictive parameters have been developed that take both pulmonary hypoplasia and pulmonary hypertension into account. ECMO additionally enables us to postpone the operation until stabilization of the newborn (Late Operation Protocol). Apart from this, we can probably improve the long-term results after ECMO by reconstructing the common carotid artery.

Reconstruction of the arteria carotis communis in newborn following extracorporeal membrane oxygenation (ECMO)

With the help of ECMO it is possible to save the lives of newborn infants suffering from severe respiratory distress syndrome not responding to conservative treatment. Using Bartlett's classic venous-arterial perfusion technique in ECMO the right arteria carotis communis had to be sacrificed. Thus, despite the life-saving character of this new method, the ligation of the carotid with all its possible complications had often been a major argument against using this therapy. We are now therefore trying to reconstruct the arteria carotis after decannulating the vessel after extracorporeal membrane oxygenation. In our 8 cases so far, post-op examinations showed no obstruction of blood flow in the vessel. No neurological deficiencies were recorded.

[Atopic gallbladder. Case report, embryologic etiology and review of the literature]

Abnormal position of the gallbladder seems to be rare, but knowledge about the varieties helps to avoid intraoperative complications regarding the spreading procedure of laparoscopic cholecystectomy. In the reported case the gallbladder was found in the lower right abdomen fixed by adhesions to the jejunum. Embryological aspects are discussed and a literature review is given.

Clinical evaluation of the Bentley Univox membrane oxygenator

This paper reports a clinical evaluation of Bentley's new Univox membrane oxygenator (Bentley Laboratories, Irvine, California). In this new device, the blood flow path is outside the fibre, the incorporated heat exchanger consists of a 22-channel stainless-steel bellows, and the polypropylene fibres are woven into fibre ribbons and wound into each of the bellows channels. In this way, heat and gas transfers take place simultaneously. The priming volume has been reduced to 220ml and the membrane has an effective surface area of 1.6m 2. A BMR 1900 collapsible reservoir (Bentley Laboratories, Irvine, California) was used as a venous reservoir. Ten consenting patients undergoing elective coronary artery bypass surgery were perfused with this new oxygenator. BSA was between 1.7 and 2.11m 2; mean BSA was 1.81. Minimum priming was 1200 ml. The blood-gas results were all within or close to the normal range used in our institution. Acid-base management was performed using alpha-stat regulation and no problems occurred in this series of patients. Average pO 2 was 155mmHG+/-53 with a mean O 2 transfer of 90.7ml and a maximum of 185ml. The heat exchange performance was very good, with a mean coefficient of heat exchange of 0.54+/-0.11 and a maximum of 0.87.

[Organ preservation by reconstruction of Wirsung's duct in complete pancreas rupture]

Blunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.

[Use of fibrin glue in prevention and therapy of intra-abdominal adhesions]

In prevention of the recurrent intestinal obstruction we performed at the Department of Pediatric Surgery of the University of Mannheim a sutureless plication of the small bowel with fibrin glue only over the last 7-year period. The postoperative course was uncomplicated in all patients. The clinical and experimental experiences suggest that the high concentrated human fibrinogen is able to start healing of the lesions of the serosa to prevent intraabdominal adhesions prospectively. Furthermore the time saving and easy procedure is to be stressed. First of all the high risk of tissue necrosis or intestinal perforation due to ischemia by sutures and stitches like in the traditional technique of plication is not present.

[Extracorporeal membrane oxygenation (ECMO). A treatment alternative for newborn infants with severe respiratory disorder]

Extracorporeal Membrane Oxygenation (ECMO) is a promising alternative for newborns with critical respiratory disease, where conservative management is no longer sufficient. - Indications for ECMO include mainly the diagnoses Persisting Pulmonary Hypertension (PPHN), Meconium-Aspiration and Congenital Diaphragmatic Hernia. In patients with a mortality-prognosis of 80-100% ECMO will raise survival rates to about 80% with a good general developmental prognosis. Conditions, trainee programs, and experiences up to the first clinical application of ECMO are reported.

[Clinical application of extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure]

ECMO is a therapeutic alternative for newborns with respiratory insufficiency unmanageable by artificial ventilation. A modified heart-lung machine well suited for long-term application is used both to support life and to take over organ function, allowing this organ to rest and to recover. The ECMO-technique as practised in our group is equivalent to the venous-arterial bypass initiated by the Bartlett-team. Venous blood is drained from the right atrium via the right internal jugular vein. After passage through a membrane oxygenator and a heat exchanger it is returned in an arterialized state to the ascending aorta via the right carotid artery. Cannulation is followed by systemic heparinization. With a roller pump extracorporeal circulation is installed for 3-6 days with flow-rates of 80-120 ml/kg/min. The operation is performed under local anesthesia in the neonatal intensive care unit. The typical course of ECMO is stabilization for the first 24-48 hours on high bypass flow rates keeping paO2 at 50-60 mmHg with minimal ventilator settings (Pmax 20 mmHg. FiO2 0.3-0.4). Bypass flow rates can be reduced for the next 24 h and the patient is taken off and decanulated while on similar ventilator settings. Because of systemic heparinization intracranial bleeding is the main complication for a newborn child on ECMO. The incidence is about 10%. Premature infants per se have a high risk of major intracranial bleeding without ECMO. Therefore contraindications are infants under 35-weeks gestation, and a hemorrhage diagnosed by ultrasound prior to ECMO. Prediction of mortality is estimated by the alveoloarterial oxygen gradient (D [Aa] O2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Imaging procedures and follow-up in pediatric surgical diseases]

The most important modern imaging diagnostics are the ultrasound, scintigraphy, computed tomography and recently the nuclear magnetic resonance (NMR). The diagnostic tools should be used one after another, always starting with the easiest to perform, with low risk and no harm to the patient, at low costs. In routine diagnostic procedures (e.g. blunt abdominal trauma) this will be the sonography. The result of the ultrasound may give rise to other, but more invasive methods. Computed tomography, e.g. may give more detailed information about position, size and operability of a tumor whereas scintigraphy has its strong point in disclosing functional organ disorders (e.g. kidney, liver and especially in splenic transplants).

Treatment of ruptured kidney by gluing with highly concentrated human fibrinogen

A complete transverse rupture of the kidney diagnosed preoperatively by IV pyelogram and selective renal angiography is reported. It could be conserved by tissue gluing with highly concentrated human fibrinogen. An IV pyelogram should always be performed, especially since immediate aortography and renal arteriography is indicated by visible extravasation of contrast medium in every case. The lesion is exactly determined in the early stage and an organ-conserving operation becomes possible. Without the availability of angiography, nephrectomy was most frequently performed.

[Surgical indications in Crohn's disease and ulcerative colitis in childhood]

Complications after ineffective medical management are indications for surgical treatment in Crohn's disease and ulcerative colitis. Immediate intervention is necessary in perforation, bleeding and intestinal obstruction, but abscess, fistulation, chronic bowel obstruction and an inflammatory tumor need also surgery without longer delay. Acute ileitis terminalis imitating acute appendicitis is an exceptional case of Crohn's disease. Local recurrence, severe abdominal pain, diarrhoea, retardation of growth and development, and risk of malignant change may be reasons for elective surgery. As development of recurrence after operation is frequent and the results of colectomy and proctocolectomy with ileostomy are not always satisfactory some caution to surgery in ulcerative colitis and Crohn's disease in childhood is advisable.

[Use of highly concentrated human fibrinogen in paediatric surgery - a new therapeutic principle (author's transl)]

When using fibrin glue we must distinguish, on the basis of the clinical results obtained, between an obsolute and a relative indication for glueing. Glueing of the oesophageal anastomosis in atresia effected by means of three of four fibres only definitely produces better results than suturing alone. Likewise, fixation of skin grafts and treatment of ruptured spleen are an exclusive indication for fibrin glueing. Endoscopic glueing of oesophagotracheal fistulas and treatment of rupture of the kidneys, liver and pancreas are essential indications for glueing, alone or together with suturing. Intestinal anastomoses which are in danger of becoming detached can be secured by means of fibrin, thus improving the results. This applies equally to all fields of plastic surgery. In bone surgery, small detached parts of cartilage or of bone can be fixed atraumatically by glueing. Finally, improved and accelerated reconstruction e.g. of removed bone cysts can be expected by inserting fibrin-spongiosa fillings.

[The tissue adhesion of the ruptured spleen with highly concentrated human fibrinogen (author's transl)]

After splenectomy the immunologic impairment and the susceptibility to infection is increased, but the most important impetus for splenic preservation has been the observation of the overwhelming postsplenectomy sepsis. Successful results with surgical repair of traumatized spleen and several different techniques have been reported. Instead of suture of splenorrhaphy we used in our experiences a new biological adhesive-system, consisting in thrombin, highly concentrated native human fibrinogen and clotting factor XIII. The highly adhesive properties, the excellent tissue compatibility and the haemostyptic effects recommend this system for using in preservation of the injured spleen as well as possible.

[Diagnostic procedure of abdominal masses in childhood (author's transl)]

As abdominal tumor in childhood show a high rate of malignancy, a quick and exact diagnostic management is necessary. Different diagnostic procedures are described and their value in finding the diagnosis is discussed.

[Roentgenological aspects of the cyst lung in newborn (author's transl)]

The article reports on the angiographic identification of a cyst lung in a newborn with special consideration of the differential diagnostic differentiation from lung sequestration which appears similar in the full size radiograph. The article also discusses further differential diagnoses, complications and treatment possibilities of cyst lungs.

[Congenital dilatations and stenoses of the bile ducts in children (author's transl)]

The congenital choledochus cyst is an extremely rare disease pattern. The author presents two own cases of boys aged 4 1/2 years in whom the disease was manifested as a fusiform dilatation of the cholodochus and of the other bile ducts on the one hand, and by a cyst in the second case. Both cases were characterised by an additional annular stenosis of the cholodochus immediately before the junction of the pancreatic duct. The article discusses the most essential criteria in respect of clinic, diagnosis and therapy, as well as the etiological aspects.

[Complications of antithrombotic prophylaxis with acetylsalicylic acid (ASS) in polycythemia (author's transl)]

Eight patients with polycythemia whose main complaints resulted from vascular complications were prophylactically treated with ASS. 4 patients tolerated the treatment without any side effects, 4 patients had an acute upper gastrointestinal hemorrhage, which was fatal in 2 cases. Correlations between the thrombohemorrhagical syndrome in polycythemia on one hand and the side effects of ASS on the other hand are discussed. As a result of this antithrombotic prophylaxis with ASS is not indicated in polycythemia even in predominance of vascular complications and absence of bleeding tendency. In life-threatening situations antithrombotic therapy with heparine should be preferred.

[Splenic cysts: clinical aspects, diagnosis and differential diagnosis]

328 patients were splenectomized from 1967 until 1976. In this period only 4 splenic cysts were observed and operated. Three cysts were posttraumatic and one was of lymphatic origin. The case history and diagnostic management is reported with special reference to preoperative angiography and differential diagnosis. There were no postoperative complications observed.

[The angiographic picture of arteriovenous fistulae (author's transl)]

The angiographic appearances and the significance of various angiographic signs are discussed in relation to 12 arteriovenous fistulae demonstrated angiographically in 11 patients. Dilatation of the supplying artery is an indication of the size of the shunt and is particularly prominent in the presence of multiple, congenital microfistulae. The technique developed in our clinic for investigating suspected or known A-V fistulae is described. This technique simplifies the differential diagnosis between the Klippel-Trénaunay syndrome and the prognostically less favourable Weber syndrome.

[Clinical importance of Meckel's diverticulum]

Between 1966 und 1975 42 children and 46 adults were operated on Meckel's diverticulum. The diverticulum is explained as one of the possible disturbances during regression of ductus omphaloentericus. The appendicitis-like symptomatology correlates to the involvement of gastric and colonic mucosa as well as heterotopic exo- and endocrine tissue of the pancreas in the wall of the diverticulum. In 34% complications were due to inflammation, perforation, bleeding, intussusception, volvulus, gut-strangulation with ileus, ulcer, neoplasia or lesion by foreign bodies. 4 out of 88 patients died. Preoperative diagnostic fails in 75%, therefore in every case the distal gut should be inspected and every diverticulum should be resected.

[Modification of hematotoxic effects of cyclophosphamide by anabolid steroids]

Human malignant tumors have been shown to be highly resistant to the chemotherapeutic agents so far available. Since these have to be administered in high doses, hematotoxic effects occur frequently during such treatment. Androgens and anabolic steroids being potent stimulators of normal and of some forms of impaired erythropoiesis, studies were initiated in rats to assess the possibility of a protective role of these steroids against the toxicity of cyclophosphamide. The following results were obtained: 1. A single dose of cyclophosphamide (100 mg/kg) significantly lowered the erythrocyte, reticulocyte, hemoglobin, leucocyte and platelet counts. 2. An initial treatment with nandrolone phenylpropionate signifiantly reduced the decrease of both the erythrocyte and the hemoglobin counts. 3. An initial treatment with metenolone enanthate (Primobolan-Depot) completely prevented the reduction of erythrocytes in appropriate experimental conditions and significantly reduced the decrease of hemoglobins. 4. There was no effect of these steroids on the drop of granulocytes, lymphocytes and platelets. These observations suggest that combination of anabolic steroid therapy with cyclophosphamide therapy may be worthy of clinical trial in patients whose tumors are not subject to growth stimulation by androgenic steroids.