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Lung surgery in neonates and infants is generally similar to that in adults except that the diminutive size, the associated lesions and the unique pathologic entities require certain special considerations. Of course, the smaller the child, the more care must be taken in order to avoid technical injury. As with all lung surgery, technical problems may result in serious and irreversible consequences. Collaboration with paediatric anaesthesiologists familiar with the unique circumstances of paediatric chest surgery is essential.

After transfer to the intensive care unit, the infant is kept warm, given maintenance requirements of intravenous fluids and has vital signs monitored closely with regular blood gas analyses and monitoring of preductal and postductal oxygenation. Ventilatory support is continued postoperatively with the aim of maintaining preductal O around 80–100 mmHg, CO up to 60 mmHg, and pH greater than 7.25 with hyperventilation (rates up to 150 per min) and the lowest possible pressures and low tidal volumes. The intrathoracic air pocket will usually reabsorb but evidence of increasing air and fluid with mediastinal shift requires insertion of a chest drain. Weaning from ventilation should be meticulous and slow as small variations in pH, O and CO will lead to persistent pulmonary hypertension. Weaning should commence with lowering of FiO, then peak pressures and finally respiratory rate.

As of January 2003, more than 19,000 neonates (74% survival) and 4,800 paediatric patients (48% survival) have been treated with ECMO. In the neonatal population, MAS is the most common indication for ECMO and carries with it a survival rate of 94%. Other frequent diagnosis (with survival rates in parentheses) include PPHN (79%), sepsis (75%), and CDH (54%). Viral pneumonia is the most common aetiology amongst the paediatric population requiring ECMO and has a 62% survival. Aspiration carries the greatest survival at 65%,where as non-ARDS respiratory failure has a 47% survival, ARDS 55%, and bacterial pneumonia 52% survival. Cardiac patients have an overall survival of 39%. Specifically, congenital defects have a 38% survival, bridge to transplant 43%, cardiomyopathy 49%, and the highest survival rate is for myocarditis, 58%.

Recent medical advances, such as permissive hypercapnea and the use of oscillatory ventilation have spared numerous babies from ECMO, yet many children still benefit from this modality. In summary, any patient with reversible cardiopulmonary disease, who meets criteria, should be considered an ECMO candidate. ECMO provides an excellent opportunity to provide “rest” to the cardiopulmonary systems and allows the patient to recover using pharmacologic and surgical therapies.

Post-operative care includes nasogastric tube drainage of the stomach and intravenous fluids are required until normal gastrointestinal function is reestablished. Post-operative antibiotics may be given for prophylaxis against wound infection if indicated.

Failure of the viteline duct to regress results in anomalies that may require resection to prevent or treat complications. The risk of post-operative complications, notably wound infection, is low and the outcome of surgery is excellent. Successful use of a laparoscopic approach for these anomalies has been reported.

The objective of pyeloplasty is to achieve a dependent, adequate calibrated watertight pelvi-ureteric junction. There are different techniques available to repair a PUJ obstruction. The dismembered Anderson-Hynes pyeloplasty is suitable for the majority of patients with PUJ obstruction. Use of double-J ureteral stents has virtually eliminated ureteral leaks and early obstructions.

The outcome for patients with gastroschisis has dramatically improved. Whereas the mortality was 80 to 90% three or four decades ago, the survival is now more than 90%. The improvement in outcome is related to the availability of intravenous nutrition and the use of staged closure when indicated. Late complications and mortality are related to sepsis either from an intra-abdominal or wound complication or from a central venous catheter placed for parental nutrition.

Once there is evidence of bowel function it is appropriate to begin enteral feeding. An elemental formula may be better tolerated. When the infant has reached adequate caloric intake enterally then discharge is appropriate.

In the absence of complications during the recovery from surgery and resolution of the bowel oedema, infants with gastroschisis usually reach goal feedings within 3–4 weeks. Long-term complications are unusual once the infants are discharged from the hospital.

Pyloromyotomy is the standard therapy for IHPS. Mortality associated with this operation is very uncommon today. Early diagnosis and proper peri-operative management reduces complications. In spite of these advances, there remains about an 8–10% incidence of associated peri-operative morbidity such as perforation, wound infection and wound dehiscence.

In an open procedure, essentially right umbilical incision and circumumbilical incision, manipulation of and tension on the pylorus to deliver it through the wound can induce oedema in muscle layer, mucosal swelling and, occasionally serosal laceration. A laparoscopic pyloromyotomy (LP) is a less traumatic operation. The tolerance of an early feeding regimen in the LP confirms that there is lack of trauma to the pylorus during the procedure. We feel this is the most considerable benefit of LP. Use of 3.0-mm instruments allow us to improve the cosmesis.

Recurrences are most likely due to proliferation of residual epithelium from cysts or sinuses. The surgical procedure should thus be performed electively soon after diagnosis. Infected cysts and sinuses are treated with antibiotics until the inflammatory signs subside, unless abscess formation mandates incision and drainage. Repeated infections render identification of the tissue layers much more difficult. Surgery after infections of remnants of the first branchial pouch carries an increased risk of facial nerve injury. In order to avoid damage to vital vascular and nerve structures it is important to confine dissection close to the sinus tract.

The outcome of patients undergoing Ladd’s procedure for isolated malrotation is very good and the majority make a full recovery. The commonest postoperative complication is adhesional obstruction (3–5%). Midgut volvulus occurs in 45–65% of children with malrotation and still carries a mortality rate of 7–15%; necrosis of more than 75% of the midgut is associated with short bowel syndrome. Up to 18% of children with short bowel syndrome on long term total parenteral nutrition have an original diagnosis of midgut volvulus.