Treatment of a densely fused fissure during thoracoscopic right middle lobectomy

Aim: To report a case of fused fissure between the right upper and middle lobes that we treated using a surgical stapler rather than a Ligasure device for the benefit of creating a better division between the right upper and middle lobes and to effectively seal the lung parenchyma. Case: A 2-year-old girl with congenital cystic adenomatoid malformation of the right middle lobe (RML) was referred to our institution for further management after a series of infections. The vein of the RML, which drains into the superior pulmonary vein, was isolated and divided using endoclips. The bronchus was then exposed and divided using endo-clips. The arteries of the RML could be identified and ligated, allowing a line demarcating the major fissure to be identified and dissected. A stapler device was then used to seal the lung parenchyma and create a division between the right upper and middle lobes. She is currently well after follow-up of 16 months, with no episodes of respiratory distress or recurrence of symptoms. Conclusion: Our technique for dividing the pulmonary vein, then the bronchus, then the pulmonary artery and finally the fused fissure is safe and could be applied whenever fused fissures are encountered during thoracoscopic pulmonary lobectomy.

Pulmonary artery diameter ratio as a prognostic indicator of congenital diaphragmatic hernia

Background Following on from an earlier study published in 2008 about left pulmonary artery(LPA)flow measured on serial echocardiography being strongly prognostic in left-sided congenital diaphragmatic hernia(CDH)and the ratio of LPA to right pulmonary artery(RPA)diameters being a simple and reliable indicator for commencing nitric oxide(NO)therapy,the ratio of LPA:RPA diameters(PA ratio orPAR)was hypothesized to possibly reflect cardiopulmonary stresses accompanying CDH better.Methods Subjects with isolated left-sided CDH treated between 2007 and 2020 at a single pediatric surgical center were recruited and classified according to survival.Data obtained retrospectively for subject demographics,clinical course,LPA/RPA diameters,and PAR were compared between survivors and non-survivors.The value of PAR for optimizing the prognostic value of PA diameter data in CDH were analyzed with receiver operating characteristic(ROC)curve analysis.Results Of 65 subjects,there were 54 survivors(82.3%)and 11 non-survivors(17.7%);7 of 11 non-survivors died before surgical repair could be performed.Mean PAR for survivors(0.851±0.152)was significantly higher than for non-survivors(0.672±0.108)(p=0.0003).Mean PAR for non-survivors was not affected by surgical repair.Characteristics of survivors were:LPA≥2 mm(n=52 of 54;mean PAR=0.866±0.146)and RPA≥3mm(n=46 of 54;mean PAR=0.857±0.152).Non-survivors with similar LPA and RPA diameters to survivors had significantly lower mean PAR.ROC curve cut-off for PAR was 0.762.Subjects with high PAR(≥0.762)required high-frequency oscillatory ventilation/NO less than subjects with low PAR(<0.762)(p=0.0244 and p=0.0485,respectively)and subjects with high PAR stabilized significantly earlier than subjects with low PAR(1.71±0.68 days vs 3.20±0.87 days)(p<0.0001).Conclusions PAR would appear to be strongly correlated with clinical outcome in CDH and be useful for planning management of cardiopulmonary instability in CDH.

Does time taken to achieve jaundice-clearance influence survival of the native liver in post-Kasai biliary atresia?

Background We reviewed the time taken for post-portoenterostomy(PE)biliary atresia(BA)patients to obtain jaundice-clearance(total bilirubin≤1.2 mg/dL;JC)post-PE to determine if JC time(JCT)is prognostic for survival of the native liver(SNL).Methods The subjects were 66 BA patients treated with PE at our institute between 1989,the year when liver transplan-tation(LTx)became available in Japan,and 2014.JCT was used to create three groups(≤30 days:n=14;31-60 days:n=31;≥61 days:n=21).Medical records were reviewed retrospectively to evaluate:age at onset of symptoms,duration of symptoms pre-PE,age and weight at PE,serum liver function tests,incidence of cholangitis,and micro-bile duct size at PE.Results Age at onset of symptoms,age and weight at PE,duration of symptoms pre-PE,and micro-bile duct size were similar for all patients in all three groups.JCT and SNL appeared to correlate because preoperative total bilirubin(7.1,9.6,10.2 mg/dL;P<0.05)was significantly lower in the JCT≤30 days group(P<0.05)while there was a significant decrease in SNL(P<0.03)and a significant increase in LTx(P<0.01)in the JCT≥61 days group.All LTx subjects who achieved JC were found to have developed cholangitis within 3 months of PE.Conclusion During the follow-up of post-PE subjects,longer JCT and cholangitis occurrence within 3 months of PE would appear to be negative prognostic factors for SNL while preoperative total bilirubin would appear to be a positive prognostic factor for SNL.

Kidney structure and function in dilating vesicoureteral reflux patients with anorectal malformation

Background We assessed the impact of anorectal malformation(ARM)on the kidneys of children with dilating vesicoureteral reflux(D-VUR)≥grade III using a simple dimercaptosuccinic acid(DMSA)scintigraphy scan based renal dysfunction score(RDS).Methods The medical records of 121 patients with D-VUR treated between 2000 and 2014 were reviewed retrospectively.After excluding patients with secondary D-VUR(n=18),presence of ARM was used to create two groups:ARM+(n=12 cases;15 ureters)and ARM-(n=91 cases;131 ureters).Types of ARM,grades of D-VUR,bladder and bowel dysfunction(BBD)and RDS were compared.Results Patient demographics,mean follow-up,grades of D-VUR and history of urinary tract infections were not significantly different.BBD was significantly higher in ARM+(41.7%versus 7.7%,p=0.0006).RDS was significantly higher in ARM+(p=0.036).Grades of D-VUR were significantly lower in ARM-with low RDS(p=0.008).During follow-up,changes in DMSA uptake over time were not observed in ARM+.Conclusions While renal cortical lesions were correlated with grade of D-VUR in ARM-and RDS was significantly higher in ARM+,BBD did not appear to contribute to progressive renal dysfunction as is commonly believed.In fact,no progression in renal cortical lesions was observed in ARM+based on RDS data.Renal cortical lesions may possibly be a feature of ARM,a topic that warrants further study.