Background/Purpose: Complications of open conversion, hypercarbia, and intestinal injury have plaguedminimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using min...Background/Purpose: Complications of open conversion, hypercarbia, and intestinal injury have plaguedminimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using minimally invasive techniques for neonatal CDH repair, we formulated preoperative selection criteria and operative techniques that would enhance chances for successful thoracoscopic primary diaphragm repair and uncomplicated outcome. Methods: During the period from January 2003 to October 2004, neonates were selected for thoracoscopic CDH repair using anatomic and physiologic criteria. Anatomically, all patients were required to have stomach in the abdomen by radiography. Physiologically, all patients were required to be on minimal ventilator support with preoperative ventilator peak inspiratory pressures in the low 20 mm Hg. No patient could have clinical evidence of pulmonary hypertension at the time of surgery. Thoracoscopic CDH repair was performed using 3 trocars (3 and 5 mm). The hernia contents were reduced into the abdomen using 5-mm Hg insufflation, and the diaphragms were repaired primarily using interrupted 3-0 Ethibond simple sutures (Ethicon, Inc, Piscataway, NJ). Posterolateral diaphragm stitches were passed around the posterolateral ribs and tied extracorporeally. Results: Thirty neonates with CDH were admitted to Children’ s Hospital Boston and Vanderbilt Children’ s Hospital during the study period. Eight patients (27% ) met selection criteria and 7 underwent thoracoscopic CDH repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without perioperative complication. Preoperative anatomic criteria correlated accurately with intact esophageal hiatus and primary diaphragm repair. Physiologically, each patient tolerated intrathoracic insufflation and CDH repair without clinical pulmonary hypertension or blood pressure lability. Three patients had intraoperative respiratory acidosis that was reversed with ventilator changes. Operative times averaged 152 minutes and ranged from 212 to 106 minutes. Postoperative mechanical ventilation ranged from 0 to 7 days, and the length of hospitalization ranged from 5 to 32 days. Longest follow-up has been 17 months. One patient required reoperation for recurrent CDH at 10 months after repair, but there have been no other long-term complications. Conclusions: Neonatal thoracoscopic CDH repair is safe in selected patients who have good preoperative pulmonary function and anatomy amenable to primary diaphragmatic repair. A wider range of neonates may be acceptable for thoracoscopic CDH repair with increasing surgical experience.展开更多
Background: Warts occur commonly in humans. Destructive modalities are generally the first physician- administered therapy. Other treatment options include immunotherapy. Intralesionalimmunotherapyusingmumps,Candida,o...Background: Warts occur commonly in humans. Destructive modalities are generally the first physician- administered therapy. Other treatment options include immunotherapy. Intralesionalimmunotherapyusingmumps,Candida,orTrichophyton skin test antigens has proved efficacy in the treatment of warts. Objectives: To determine rates of wart resolution in response to injection of antigen alone, antigen plus interferon alfa- 2b, interferon alfa- 2b alone, and normal saline; and to compare response according to viral type, major histocompatibility complex antigens, and peripheral blood mononuclear cell proliferation to autologous human papillomavirus antigen before and after injection. Design: Randomized, single- blinded, placebo- controlled, clinical trial. Setting: Medical school- based dermatology department. Patients: Two hundred thirty- three patients clinically diagnosed as having 1 or more warts. Main Outcome Measure: Clinical resolution of warts in response to intralesional immunotherapy. Results: Responders were observed in all treatment arms, but were significantly more likely to have received antigen (P < .001). Resolution of distant untreated warts was observed, and was significantly more likely in subjects receiving antigen (P < .001). Interferon did not significantly enhance the response rate (P=.20) and did not differ from normal saline (P=.65). No viral type or major histocompatibility complex antigen correlated with response or lack of response (P > .99 and P=.86, respectively). A positive peripheral blood mononuclear cell proliferation assay result (2 times pretreatment levels) was significantly more likely among responders (P=.002). While there was no significant difference in response based on sex (P=.56), older subjects (>40 years) were less likely to respond (P=.01). Conclusions: Intralesional immunotherapy using injection of Candida, mumps, or Trichophyton skin test antigens is an effective treatment for warts, as indicated by significantly higher response rates and distant response rates in subjects receiving antigen. Viral type and major histocompatibility complex antigens did not seem to influence treatment response. Response is accompanied by proliferation of peripheral blood mononuclear cells to human papillomavirus antigens, suggesting that a human papilloma- virus- directed cell- mediated immune response plays a role in wart resolution.展开更多
文摘Background/Purpose: Complications of open conversion, hypercarbia, and intestinal injury have plaguedminimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using minimally invasive techniques for neonatal CDH repair, we formulated preoperative selection criteria and operative techniques that would enhance chances for successful thoracoscopic primary diaphragm repair and uncomplicated outcome. Methods: During the period from January 2003 to October 2004, neonates were selected for thoracoscopic CDH repair using anatomic and physiologic criteria. Anatomically, all patients were required to have stomach in the abdomen by radiography. Physiologically, all patients were required to be on minimal ventilator support with preoperative ventilator peak inspiratory pressures in the low 20 mm Hg. No patient could have clinical evidence of pulmonary hypertension at the time of surgery. Thoracoscopic CDH repair was performed using 3 trocars (3 and 5 mm). The hernia contents were reduced into the abdomen using 5-mm Hg insufflation, and the diaphragms were repaired primarily using interrupted 3-0 Ethibond simple sutures (Ethicon, Inc, Piscataway, NJ). Posterolateral diaphragm stitches were passed around the posterolateral ribs and tied extracorporeally. Results: Thirty neonates with CDH were admitted to Children’ s Hospital Boston and Vanderbilt Children’ s Hospital during the study period. Eight patients (27% ) met selection criteria and 7 underwent thoracoscopic CDH repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without perioperative complication. Preoperative anatomic criteria correlated accurately with intact esophageal hiatus and primary diaphragm repair. Physiologically, each patient tolerated intrathoracic insufflation and CDH repair without clinical pulmonary hypertension or blood pressure lability. Three patients had intraoperative respiratory acidosis that was reversed with ventilator changes. Operative times averaged 152 minutes and ranged from 212 to 106 minutes. Postoperative mechanical ventilation ranged from 0 to 7 days, and the length of hospitalization ranged from 5 to 32 days. Longest follow-up has been 17 months. One patient required reoperation for recurrent CDH at 10 months after repair, but there have been no other long-term complications. Conclusions: Neonatal thoracoscopic CDH repair is safe in selected patients who have good preoperative pulmonary function and anatomy amenable to primary diaphragmatic repair. A wider range of neonates may be acceptable for thoracoscopic CDH repair with increasing surgical experience.
文摘Background: Warts occur commonly in humans. Destructive modalities are generally the first physician- administered therapy. Other treatment options include immunotherapy. Intralesionalimmunotherapyusingmumps,Candida,orTrichophyton skin test antigens has proved efficacy in the treatment of warts. Objectives: To determine rates of wart resolution in response to injection of antigen alone, antigen plus interferon alfa- 2b, interferon alfa- 2b alone, and normal saline; and to compare response according to viral type, major histocompatibility complex antigens, and peripheral blood mononuclear cell proliferation to autologous human papillomavirus antigen before and after injection. Design: Randomized, single- blinded, placebo- controlled, clinical trial. Setting: Medical school- based dermatology department. Patients: Two hundred thirty- three patients clinically diagnosed as having 1 or more warts. Main Outcome Measure: Clinical resolution of warts in response to intralesional immunotherapy. Results: Responders were observed in all treatment arms, but were significantly more likely to have received antigen (P < .001). Resolution of distant untreated warts was observed, and was significantly more likely in subjects receiving antigen (P < .001). Interferon did not significantly enhance the response rate (P=.20) and did not differ from normal saline (P=.65). No viral type or major histocompatibility complex antigen correlated with response or lack of response (P > .99 and P=.86, respectively). A positive peripheral blood mononuclear cell proliferation assay result (2 times pretreatment levels) was significantly more likely among responders (P=.002). While there was no significant difference in response based on sex (P=.56), older subjects (>40 years) were less likely to respond (P=.01). Conclusions: Intralesional immunotherapy using injection of Candida, mumps, or Trichophyton skin test antigens is an effective treatment for warts, as indicated by significantly higher response rates and distant response rates in subjects receiving antigen. Viral type and major histocompatibility complex antigens did not seem to influence treatment response. Response is accompanied by proliferation of peripheral blood mononuclear cells to human papillomavirus antigens, suggesting that a human papilloma- virus- directed cell- mediated immune response plays a role in wart resolution.
