Journal of pediatric surgery
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Despite the dramatic improvement in the outcome of somatically handicapped neonates, vexing ethical issues remain. In which fetuses would termination be indicated? In which neonates are the malformations so serious that surgery and intensive care should not be initiated (withholding or not starting treatment)? Conversely, in which neonates should the initiated treatment be stopped (withdrawal of treatment)? These questions pose huge medical, legal, ethical, moral, and financial problems for doctors, lawyers, ethicists, and families. ⋯ The decision making should be tailored to each of these groups. The pediatric surgeon, besides taking into consideration the quantity and quality of the rescued life, should lower the anxiety of the parents, should follow the morals of a civilized society, should act according to the law, and finally, should convince himself to be a solution to a problem and not to be a cause of any.
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Review Case Reports
Challenges to cannulation for extracorporeal support in neonates with right-sided congenital diaphragmatic hernia.
Right-sided diaphragmatic defects represent less than 20% of all congenital diaphragmatic hernias (CDH). Recent data suggest that right CDH (R-CDH) may carry a disproportionately high morbidity as well as increased rates of extracorporeal support when compared with left CDH. Treatment of infants with R-CDH may be further complicated by anatomical distortion unique to right-sided defects. ⋯ At autopsy, a dilated azygous vein was evident as a result of inferior vena cava compression by a malpositioned liver. The possibility of azygous vein cannulation may be increased in neonates with R-CDH and has not been previously reported. When evaluating infants with R-CDH for ECMO, clinicians must recognize the possibility of azygous cannulation and its potentially lethal consequences, and should anticipate alternative venous cannulation.
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Review Case Reports
Extracranial carotid arteries aneurysms in children: single-center experiences in 4 patients and review of the literature.
Extracranial carotid artery aneurysms (ECAAs) are very rare conditions in children but carry a great potential of thromboembolic episodes and ruptures. ⋯ Although very rare, ECAA can be encountered even in the pediatric population. The past medical history may reveal a tonsillectomy, although the relation may not be easy to establish. Local signs may be accompanied by hemispheric thromboembolic complications, rupture, and bleeding. Therefore, surgical treatment is indicated, but can be challenging according to the anatomical location of the aneurysm.
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Review Case Reports
Lung torsion after tracheoesophageal fistula repair: a case report and review of literature.
Lung torsion is a very rare event that has been described after trauma, spontaneously, and post-thoracic surgery, with only 8 cases reported in the pediatric literature. We present the first case report of lung torsion complicating tracheoesophageal fistula repair. The diagnosis was suggested on chest ultrasonogram and Doppler and confirmed by computed tomographic scans. ⋯ It causes clinical deterioration in the face of normal arterial blood gases and requires a high index of suspicion for diagnosis. Resection of the twisted lung or lobe may be unnecessary if diagnosis is made early and vascular occlusion is partial. Patients with complete interlobar fissures may benefit from pulmonary lobe fixation as a prophylaxis against occurrence or recurrence of this complication.
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Although hepatic tumors are uncommon in the perinatal period they are associated with significant morbidity and mortality in affected patients. The purpose of this review is to focus on the fetus and neonate in an attempt to determine the various ways liver tumors differ clinically and pathologically from those found in the older child and adult and to show that certain types of tumors have a better prognosis than others. ⋯ The study shows that clinical findings in fetuses and neonates with hepatic tumors are less well defined than in older children. Survival rates are much lower as well. When the clinical course is complicated by associated conditions such as stillbirth, fetal hydrops, congestive heart failure, severe anemia, or thrombocytopenia, the mortality rate is much greater. If the patient is mature enough and in a clinical condition where he or she can be operated on, survival figures approach those of the older child. Some hepatic tumors have a better prognosis than others. Neonates with focal (solitary) hepatic hemangiomas have the best outcome and fetuses with hepatoblastoma the worst. Although infantile hemangioma undergoes spontaneous regression, it may be life threatening when congestive heart failure and/or consumptive coagulopathy occur. Mesenchymal hamartoma is a benign lesion best treated by surgical resection, which usually results in cure. However, there are fatal complications associated with this tumor, ie, fetal hydrops, respiratory distress, and circulatory problems owing to a large space occupying abdominal lesion and sometimes stillbirth, all contributing to the death rate. Hepatoblastoma, the major malignancy of the fetus and neonate, is treated primarily by surgical resection. Pre- or postoperative chemotherapy is reserved for those patients with unresectable tumors or metastatic disease. The survival rate is much lower than that reported by multigroup prospective trials. Patients die from the mass effect caused by the tumor, which lead to abdominal distension, vascular compromise, anemia, hydrops, respiratory distress, and stillbirth. Metastases to the abdominal cavity, lungs, and placenta are other causes of death. Because of the danger of labor-induced rupture of the tumor and potentially fatal intraabdominal hemorrhage, cesarean delivery is recommended when a hepatic tumor is found on prenatal ultrasound.