Considerations of single-lung ventilation in neonatal thoracoscopic surgery with cardiac arrest caused by bilateral pneumothorax:A case report

BACKGROUND Tension pneumothorax of the contralateral lung during single-lung ventilation(SLV)combined with artificial pneumothorax can cause cardiac arrest due to bilateral pneumothorax.If not rapidly diagnosed and managed,this condition can lead to sudden death.We describe the emergency handling procedures and rapid diagnostic methods for this critical emergency situation.CASE SUMMARY We report a case of bilateral pneumothorax in a neonatal patient who underwent thoracoscopic esophageal atresia and tracheoesophageal fistula repair under the combined application of SLV and artificial pneumothorax.The patient suffered sudden cardiac arrest and received emergency treatment to revive her.The recognition of dangerous vital sign parameters,rapid evacuation of the artificial pneumothorax,and initiation of lateral position cardiopulmonary resuscitation while simultaneously removing the endotracheal tube to the main airway are critically important.Moreover,even though the sinus rhythm was restored,the patient’s continued tachycardia,reduced pulse pressure,and depressed pulse oximeter waveform were worrisome.We should highly suspect the possibility of pneumothorax and use rapid diagnostic methods to make judgment calls.Sometimes thoracoscopy can be used for rapid examination;if the mediastinum is observed to be shifted to the right,it may indicate tension pneumothorax.This condition can be immediately relieved by needle thoracentesis,ultimately allowing the safe completion of the surgical procedure.CONCLUSION Bilateral pneumothorax during SLV combined with artificial pneumothorax is rare but can occur at any time in neonatal thoracoscopic surgery.Therefore,anesthesiologists should consider this possibility,be alert,and address this rare but critical complication in a timely manner.

Surgical Repair of Ventricular Septal Defect in Neonates: Indications and Outcomes

Background:The optimal surgical timing and clinical outcomes of ventricular septal defect(VSD)closure in neo-nates remain unclear.We aimed to evaluate the clinical outcomes of VSD closure in neonates(age≤30 days).Methods:We retrospectively reviewed 50 consecutive neonates who underwent VSD closure for isolated VSDs between August 2003 and June 2021.Indications for the procedure included congestive heart failure/failure to thrive and pulmonary hypertension.Major adverse events(MAEs)were defined as the composite of all-cause mortality,reoperation,persistent atrioventricular block,and significant(≥grade 2)valvular dysfunction.Results:The median age and body weight at operation were 26.0 days(interquartile range[IQR],18.8–28.3)and 3.7 kg(IQR,3.3–4.2),respectively.The median follow-up duration was 110.4 months(IQR,56.8–165.0).Seven patients required preoperative respiratory support,andfive had significant(≥grade 2)preoperative valvular dysfunction.One early mortality occurred due to irreversible cardiogenic shock;no late mortality was observed.One reopera-tion was due to hemodynamically significant residual VSD at 103.8 months postoperatively.The overall survival,freedom from reoperation,and freedom from MAE at 15-years were 98.0%,96.3%,and 94.4%,respectively.Pre-operative mechanical ventilation was associated with a longer duration of postoperative mechanical ventilation(p<0.001)and a longer length of intensive care unit stay(p<0.001).Conclusions:VSD closure with favorable outcomes without morbidities is feasible even in neonates.However,neonates requiring preoperative respiratory support may require careful postoperative management considering the long-term postoperative risks.Overall,surgical VSD closure might be indicated earlier in neonates with respiratory compromise.

Review. Gastrointestinal Surgery in Neonates: Practice, Facts, and Trends

The author presents an overview of the current trends in acute neonatal gastrointestinal surgery. Necrotizing enterocolitis and focal intestinal perforation are disorders of different etiology, appearance, and prognosis. In neonates with focal perforation, a good prognosis can be expected. Primary anastomosis is a valid option for primary surgery. Meconium ileus is based on obstruction of the terminal ileum. Medical treatment is the primary therapeutic option, although surgery may be required. In contrast, meconium plug syndrome is based on stool plugging in the left colon, and surgery is not appropriate. Hirschsprung’s disease is confirmed on the basis of representative biopsy of the rectum just above the dentate line. There is a trend toward a single-step pull-through operation without protective stoma. Open hernia repair in small neonates can be performed via a mini-incision and without opening the external inguinal ring. Laparoscopic hernia repair has some advantages, especially in girls. In infants with pyloric stenosis, laparoscopic pyloromyotomy is a first line option for treatment. There is a general trend toward single-stage procedures and laparoscopic reconstructive surgery for gastrointestinal malformations. With the exception of tracheoesophageal fistula and low bowel obstruction, the vast majority of upper gastrointestinal malformations can be identified using prenatal ultrasound examination. One-stage repair with excellent results is even possible in neonates below 1000 g. Surgery of duodenal or small bowel atresia can be performed following the postnatal adaptation period. For some forms of anorectal malformation, the need for a protective stoma has been questioned in the last decade. Posterior sagittal anorectoplasty remains the standard procedure for the majority of cases. Midgut or segmental volvulus affects different groups of infants. If a neonate is suspected of having any type of volvulus, urgent surgery is required. Intestinal duplication carries a high risk for complications, and surgery should be performed on an elective basis.

Delivery room surgery:an applicable therapeutic strategy for gastroschisis in developing countries

Background:The survival rate of infants with gastroschisis has improved significantly.It is over 90%in developed countries,but 50%in developing countries.This study aimed to investigate the factors improving the survival rate of infants with gastroschisis in developing countries.Methods:Neonates meeting the inclusion criteria,who presented to our center since the establishment of delivery room surgery,were enrolled into this retrospective study.Data were evaluated specifically to determine the role of delivery room surgery in reducing the mortality and morbidity of infants with gastroschisis and to identify factors optimizing the conditions of outborn infants.Results:A total of 64 infants were identified.The overall survival rate of the infants was 60.9%.The survival rate of infants in inborns was 76.5%,and the survival rate of infants in outborns was 43.3%.Infants of the outborn group took more time to reach full enteral feeding,and were more likely to require a prolonged stay in hospital when compared with those of the inborn group.Logistic analysis identified that the surgical technique,the presence of sepsis and intestinal necrosis could be expected to influence the outcome of gastroschisis.Conclusions:The strategy of delivery of patients in a center prepared to perform delivery room closure of gastroschisis appears to improve the survival of patients with gastroschisis.Further reduction in mortality rates will depend on improved conditions of outborn infants.