Journal of Thoracic and Cardiovascular Surgery, 2004
Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Mana... more Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Management remains controversial. A multidisciplinary tracheal team was formed in 2000 to deal with a large number of children with airway problems referred for management. We review the effect of that service, comparing the era before and after the establishment of the multidisciplinary tracheal team. Methods: From January 1998 through January 2004, 34 patients with long-segment tracheal stenosis (21 patients with cardiovascular anomalies) underwent surgical intervention. Cardiopulmonary bypass was used in all operations. Before the multidisciplinary tracheal team, pericardial patch tracheoplasty with or without an autograft technique was the preferred method of repair. After the multidisciplinary tracheal team, an integrated care plan preferring slide tracheoplasty was initiated, correcting cardiac lesions simultaneously. Results: Before the establishment of the multidisciplinary tracheal team, pericardial patch tracheoplasty was performed in 15 of 19 patients. Twelve patients had a suspended pericardial patch tracheoplasty, 2 (17%) of whom died late after the operation. Of 3 patients who had had a simple unsuspended patch, 2 (67%) died early after the operation. Four patients were operated on with the tracheal autograft technique, 2 (50%) dying early in the postoperative period. After multidisciplinary tracheal team formation, in the era between 2001 and 2004, 15 patients were operated on with slide tracheoplasty, and there were 2 (13%) early postoperative deaths. A significant reduction in cost and duration of stay has been shown both in the intensive care unit and the hospital. Conclusion: Our data suggest that a formalized multidisciplinary team approach and a policy of primary slide tracheoplasty are beneficial in the management of children with long-segment tracheal stenosis. L ong-segment tracheal stenosis (LSTS) in children is rare and potentially life-threatening, and the treatment remains controversial. Over the years, we have used a number of therapeutic options. 1 Several specialty groups were involved, with interactions based on a consultation-when-needed policy. We had evolved an ad hoc policy involving slide tracheoplasty (STP) 1 for short-and medium-length stenosis and, on the basis of the late 1990s literature, 2,3 patch tracheoplasty (PTP) for long or very long stenoses. Stenting was used for early failure, and tracheal homograft patch repair 4 was used for late recurrence.
We reviewed both the North American and the total worldwide pediatric experience with tracheal al... more We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.
We reviewed both the North American and the total worldwide pediatric experience with tracheal al... more We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.
Background Stem-cell-based, tissue engineered transplants might off er new therapeutic options fo... more Background Stem-cell-based, tissue engineered transplants might off er new therapeutic options for patients, including children, with failing organs. The reported replacement of an adult airway using stem cells on a biological scaff old with good results at 6 months supports this view. We describe the case of a child who received a stem-cell-based tracheal replacement and report fi ndings after 2 years of follow-up.
Tissue engineering of autologous lung tissue aims to become a therapeutic alternative to transpla... more Tissue engineering of autologous lung tissue aims to become a therapeutic alternative to transplantation. Efforts published so far in creating scaffolds have used harsh decellularization techniques that damage the extracellular matrix (ECM), deplete its components and take up to 5 weeks to perform. The aim of this study was to create a lung natural acellular scaffold using a method that will reduce the time of production and better preserve scaffold architecture and ECM components. Decellularization of rat lungs via the intratracheal route removed most of the nuclear material when compared to the other entry points. An intermittent inflation approach that mimics lung respiration yielded an acellular scaffold in a shorter time with an improved preservation of pulmonary micro-architecture. Electron microscopy demonstrated the maintenance of an intact alveolar network, with no evidence of collapse or tearing. Pulsatile dye injection via the vasculature indicated an intact capillary network in the scaffold. Morphometry analysis demonstrated a significant increase in alveolar fractional volume, with alveolar size analysis confirming that alveolar dimensions were maintained. Biomechanical testing of the scaffolds indicated an increase in resistance and elastance when compared to fresh lungs. Staining and quantification for ECM components showed a presence of collagen, elastin, GAG and laminin. The intratracheal intermittent decellularization methodology could be translated to sheep lungs, demonstrating a preservation of ECM components, alveolar and vascular architecture. Decellularization treatment and methodology preserves lung architecture and ECM whilst reducing the production time to 3 h. Cell seeding and in vivo experiments are necessary to proceed towards clinical translation.
Stem cell-based tissue-engineered tracheas are at an early stage in their product development cyc... more Stem cell-based tissue-engineered tracheas are at an early stage in their product development cycle. Tens of patients have been treated worldwide in predominantly compassionate use settings, demonstrating significant promise. This potentially life-saving treatment is complex, and the cost and its implications for such treatments are yet to be fully understood. The costs are compounded by varying strategies for graft preparation and transplant, resulting in differing clinical and laboratory costs from different research groups. Here we present a detailed breakdown of the clinical and manufacturing costs for three of the UK patients treated with such transplants. All three patients were treated under Compassionate Use legislation, within the UK National Health Service (NHS) hospital setting. The total costs for the three UK patients treated ranged from approximately $174,420 to $740,500. All three patients were in a state of poor health at time of treatment and had a number of complexities in addition to the restricted airway. This is the first time a cost-analysis has been made for a tissue-engineered organ and provides a benchmark for future studies, as well as comparative data for use in reimbursement considerations.
This paper aims to update clinicians on "hot topics" in the management of patients with D-loop tr... more This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E 1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E 1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early-and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO. (J Am Coll Cardiol 2014;64:498-511)
Traumatic diaphragmatic hernias, although not uncommon, present infrequently enough to cause diag... more Traumatic diaphragmatic hernias, although not uncommon, present infrequently enough to cause diagnostic difficulty, particularly in the acute phase. Blunt injuries account for more diaphragmatic ruptures than direct trauma and the ruptures are usually left sided. The case presented here is reported because of its dramatic manifestation, several years after the initial injury.
... Belgium Duccio Di Carlo Rome, Italy Roberto Di Donato Rome, Italy Tjark Ebels Groningen, the ... more ... Belgium Duccio Di Carlo Rome, Italy Roberto Di Donato Rome, Italy Tjark Ebels Groningen, the Netherlands Martin J. Elliott London, UK Josè Fragata Lisbon, Portugal Victor Hraska Hamburg, Germany Jeffrey Jacobs St ... 5. Norwood WI, Lang P, Casteneda AR, Campbell DN. ...
The Journal of Thoracic and Cardiovascular Surgery, Feb 1, 2011
In the current era of advanced cardiac surgery and extracorporeal membrane oxygenation (ECMO), th... more In the current era of advanced cardiac surgery and extracorporeal membrane oxygenation (ECMO), there are serious limitations with inadequate neuromonitoring, misleading neuromonitoring, or both, especially in the setting of hemodilution and nonpulsatile flow. 1 Multimodal neurological monitoring is available and advocated in certain centers. 2 However, the implications of neurological monitoring with relevance to neurodevelopmental outcome have not been clearly delineated. As a result, there is equipoise about routine neuromonitoring, particularly with near-infrared spectroscopy (NIRS) and the relevance of data. Single-or dual-channel NIRS has been used widely in cardiac theaters. 4 In a previous study we used dual-channel NIRS in patients undergoing ECMO to understand cerebral and peripheral tissue oxygenation. 5 Power spectral density analysis was performed to extract vasomotion and respiratory and cardiac oscillations. To date, most NIRS studies have used optodes placed on the forehead, which monitor only a small area of the anterior cerebrum. We have developed a novel multichannel NIRS protocol for providing regional measures of cerebral oxygenation and hemodynamics for use in cardiac theaters and intensive care units. Because ECMO in the cardiac intensive care unit could be a surrogate model similar to a patient undergoing cardiac surgery during cardiopulmonary bypass, we have carried out preliminary studies on patients undergoing ECMO during manipulations in the ECMO circuit blood flows. We present our preliminary results with our first patient undergoing ECMO in which we have identified differences in regional cerebral oxygenation with changes in ECMO flows.
Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from extern... more Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.
American Journal of Respiratory and Critical Care Medicine, Dec 20, 2012
Despite increasing incidence and morbidity, little evidence exists to inform the best management ... more Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema. To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema. Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs. Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001). There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.
Journal of Thoracic and Cardiovascular Surgery, 2004
Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Mana... more Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Management remains controversial. A multidisciplinary tracheal team was formed in 2000 to deal with a large number of children with airway problems referred for management. We review the effect of that service, comparing the era before and after the establishment of the multidisciplinary tracheal team. Methods: From January 1998 through January 2004, 34 patients with long-segment tracheal stenosis (21 patients with cardiovascular anomalies) underwent surgical intervention. Cardiopulmonary bypass was used in all operations. Before the multidisciplinary tracheal team, pericardial patch tracheoplasty with or without an autograft technique was the preferred method of repair. After the multidisciplinary tracheal team, an integrated care plan preferring slide tracheoplasty was initiated, correcting cardiac lesions simultaneously. Results: Before the establishment of the multidisciplinary tracheal team, pericardial patch tracheoplasty was performed in 15 of 19 patients. Twelve patients had a suspended pericardial patch tracheoplasty, 2 (17%) of whom died late after the operation. Of 3 patients who had had a simple unsuspended patch, 2 (67%) died early after the operation. Four patients were operated on with the tracheal autograft technique, 2 (50%) dying early in the postoperative period. After multidisciplinary tracheal team formation, in the era between 2001 and 2004, 15 patients were operated on with slide tracheoplasty, and there were 2 (13%) early postoperative deaths. A significant reduction in cost and duration of stay has been shown both in the intensive care unit and the hospital. Conclusion: Our data suggest that a formalized multidisciplinary team approach and a policy of primary slide tracheoplasty are beneficial in the management of children with long-segment tracheal stenosis. L ong-segment tracheal stenosis (LSTS) in children is rare and potentially life-threatening, and the treatment remains controversial. Over the years, we have used a number of therapeutic options. 1 Several specialty groups were involved, with interactions based on a consultation-when-needed policy. We had evolved an ad hoc policy involving slide tracheoplasty (STP) 1 for short-and medium-length stenosis and, on the basis of the late 1990s literature, 2,3 patch tracheoplasty (PTP) for long or very long stenoses. Stenting was used for early failure, and tracheal homograft patch repair 4 was used for late recurrence.
We reviewed both the North American and the total worldwide pediatric experience with tracheal al... more We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.
We reviewed both the North American and the total worldwide pediatric experience with tracheal al... more We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.
Background Stem-cell-based, tissue engineered transplants might off er new therapeutic options fo... more Background Stem-cell-based, tissue engineered transplants might off er new therapeutic options for patients, including children, with failing organs. The reported replacement of an adult airway using stem cells on a biological scaff old with good results at 6 months supports this view. We describe the case of a child who received a stem-cell-based tracheal replacement and report fi ndings after 2 years of follow-up.
Tissue engineering of autologous lung tissue aims to become a therapeutic alternative to transpla... more Tissue engineering of autologous lung tissue aims to become a therapeutic alternative to transplantation. Efforts published so far in creating scaffolds have used harsh decellularization techniques that damage the extracellular matrix (ECM), deplete its components and take up to 5 weeks to perform. The aim of this study was to create a lung natural acellular scaffold using a method that will reduce the time of production and better preserve scaffold architecture and ECM components. Decellularization of rat lungs via the intratracheal route removed most of the nuclear material when compared to the other entry points. An intermittent inflation approach that mimics lung respiration yielded an acellular scaffold in a shorter time with an improved preservation of pulmonary micro-architecture. Electron microscopy demonstrated the maintenance of an intact alveolar network, with no evidence of collapse or tearing. Pulsatile dye injection via the vasculature indicated an intact capillary network in the scaffold. Morphometry analysis demonstrated a significant increase in alveolar fractional volume, with alveolar size analysis confirming that alveolar dimensions were maintained. Biomechanical testing of the scaffolds indicated an increase in resistance and elastance when compared to fresh lungs. Staining and quantification for ECM components showed a presence of collagen, elastin, GAG and laminin. The intratracheal intermittent decellularization methodology could be translated to sheep lungs, demonstrating a preservation of ECM components, alveolar and vascular architecture. Decellularization treatment and methodology preserves lung architecture and ECM whilst reducing the production time to 3 h. Cell seeding and in vivo experiments are necessary to proceed towards clinical translation.
Stem cell-based tissue-engineered tracheas are at an early stage in their product development cyc... more Stem cell-based tissue-engineered tracheas are at an early stage in their product development cycle. Tens of patients have been treated worldwide in predominantly compassionate use settings, demonstrating significant promise. This potentially life-saving treatment is complex, and the cost and its implications for such treatments are yet to be fully understood. The costs are compounded by varying strategies for graft preparation and transplant, resulting in differing clinical and laboratory costs from different research groups. Here we present a detailed breakdown of the clinical and manufacturing costs for three of the UK patients treated with such transplants. All three patients were treated under Compassionate Use legislation, within the UK National Health Service (NHS) hospital setting. The total costs for the three UK patients treated ranged from approximately $174,420 to $740,500. All three patients were in a state of poor health at time of treatment and had a number of complexities in addition to the restricted airway. This is the first time a cost-analysis has been made for a tissue-engineered organ and provides a benchmark for future studies, as well as comparative data for use in reimbursement considerations.
This paper aims to update clinicians on "hot topics" in the management of patients with D-loop tr... more This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E 1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E 1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early-and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO. (J Am Coll Cardiol 2014;64:498-511)
Traumatic diaphragmatic hernias, although not uncommon, present infrequently enough to cause diag... more Traumatic diaphragmatic hernias, although not uncommon, present infrequently enough to cause diagnostic difficulty, particularly in the acute phase. Blunt injuries account for more diaphragmatic ruptures than direct trauma and the ruptures are usually left sided. The case presented here is reported because of its dramatic manifestation, several years after the initial injury.
... Belgium Duccio Di Carlo Rome, Italy Roberto Di Donato Rome, Italy Tjark Ebels Groningen, the ... more ... Belgium Duccio Di Carlo Rome, Italy Roberto Di Donato Rome, Italy Tjark Ebels Groningen, the Netherlands Martin J. Elliott London, UK Josè Fragata Lisbon, Portugal Victor Hraska Hamburg, Germany Jeffrey Jacobs St ... 5. Norwood WI, Lang P, Casteneda AR, Campbell DN. ...
The Journal of Thoracic and Cardiovascular Surgery, Feb 1, 2011
In the current era of advanced cardiac surgery and extracorporeal membrane oxygenation (ECMO), th... more In the current era of advanced cardiac surgery and extracorporeal membrane oxygenation (ECMO), there are serious limitations with inadequate neuromonitoring, misleading neuromonitoring, or both, especially in the setting of hemodilution and nonpulsatile flow. 1 Multimodal neurological monitoring is available and advocated in certain centers. 2 However, the implications of neurological monitoring with relevance to neurodevelopmental outcome have not been clearly delineated. As a result, there is equipoise about routine neuromonitoring, particularly with near-infrared spectroscopy (NIRS) and the relevance of data. Single-or dual-channel NIRS has been used widely in cardiac theaters. 4 In a previous study we used dual-channel NIRS in patients undergoing ECMO to understand cerebral and peripheral tissue oxygenation. 5 Power spectral density analysis was performed to extract vasomotion and respiratory and cardiac oscillations. To date, most NIRS studies have used optodes placed on the forehead, which monitor only a small area of the anterior cerebrum. We have developed a novel multichannel NIRS protocol for providing regional measures of cerebral oxygenation and hemodynamics for use in cardiac theaters and intensive care units. Because ECMO in the cardiac intensive care unit could be a surrogate model similar to a patient undergoing cardiac surgery during cardiopulmonary bypass, we have carried out preliminary studies on patients undergoing ECMO during manipulations in the ECMO circuit blood flows. We present our preliminary results with our first patient undergoing ECMO in which we have identified differences in regional cerebral oxygenation with changes in ECMO flows.
Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from extern... more Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.
American Journal of Respiratory and Critical Care Medicine, Dec 20, 2012
Despite increasing incidence and morbidity, little evidence exists to inform the best management ... more Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema. To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema. Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs. Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001). There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.
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