Understanding complications of surgery in infancy

This thesis investigates complications of surgery in infants, particularly infections and liver disease in infants receiving parenteral nutrition (PN) following gastrointestinal surgery, and intraoperative hypercapnia and acidosis in surgery for congenital diaphragmatic hernia (CDH) and oesophageal atresia with tracheo-oesophageal fistula (OA/TOF), using a series of clinical studies. A pilot randomised controlled trial comparing open versus thoracoscopic surgery in neonates with CDH and OA/TOF showed that neonatal thoracoscopy resulted in more severe intraoperative hypercapnia and acidosis than open surgery, particularly in patients with CDH. This highlights a need for studies assessing neurodevelopmental outcomes following neonatal thoracoscopy. In surgical infants receiving PN, chlorhexidine antisepsis to clean central venous catheter connectors was associated with a significant reduction in the rate of septicaemia (particularly staphylococcal). In such infants, septicaemia due to bowel organisms occurred later than septicaemia due to coagulase-negative staphylococci. In congenital duodenal obstruction, while avoidance of initial PN was successful for two thirds of cases in which it was attempted, one third subsequently required PN, and this group showed poorer growth than children who commenced PN soon after surgery. One third of surgical infants with intestinal failure develop intestinal failure associated liver disease (IFALD), and 61% developed septicaemia. I found no association between septicaemia and IFALD. In a randomised controlled trial to investigate whether glutamine supplementation affects the incidence of microbial invasion in surgical infants receiving PN, microbial invasion was detected by blood cultures, broad-range and targeted PCR for bacterial DNA, and assays of endotoxin, and lipopolysaccharide binding protein. Monocyte HLA-DR expression was measured by flow cytometry. Glutamine had no effect on microbial invasion, which was detected in 60% of patients (half of which was detected by blood culture). Glutamine supplementation significantly enhanced recovery of monocyte function. Among patients with low monocyte function at enrolment, glutamine was protective against microbial invasion.

[1]  M. Pakarinen,et al.  Outcome of esophageal atresia beyond childhood. , 2009, Seminars in pediatric surgery.

[2]  Neal S. Gerstein,et al.  Arterial to endtidal carbon dioxide gradient during pediatric laparoscopic fundoplication , 2008, Paediatric anaesthesia.

[3]  S. Eaton,et al.  Factors affecting 13C-natural abundance measurement of breath carbon dioxide during surgery: absorption of carbon dioxide during endoscopic procedures. , 2008, Rapid communications in mass spectrometry : RCM.

[4]  A. Capek,et al.  Effect of patient weight and anesthetic technique on CO2 excretion during thoracoscopy in children assessed by end-tidal CO2. , 2008, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[5]  S. Rothenberg.  Principles of Thoracoscopy , 2008 .

[6]  I. Conacher,et al.  Anesthesia for thoracoscopic surgery , 2007, Journal of Minimal Access Surgery.

[7]  S. Baroncini,et al.  Thoracoscopy in children: anaesthesiological implications and case reports. , 2007, Minerva anestesiologica.

[8]  F. Varlet,et al.  Multicentric assessment of the safety of neonatal videosurgery , 2007, Surgical Endoscopy.

[9]  S. Eaton,et al.  Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric technique. , 2006, British journal of anaesthesia.

[10]  M. Horibe,et al.  Monitoring cerebral oxygenation in a pediatric patient undergoing surgery for vascular ring , 2006, Paediatric anaesthesia.

[11]  N. Kalfa,et al.  Tolerance of Laparoscopy and Thoracoscopy in Neonates , 2005, Pediatrics.

[12]  Sidney M. Johnson,et al.  Neonatal thoracoscopic repair of congenital diaphragmatic hernia: selection criteria for successful outcome. , 2005, Journal of pediatric surgery.

[13]  A. Baxter,et al.  Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: anesthetic and intensive care management of a series of eight neonates , 2005, Paediatric anaesthesia.

[14]  C. Bannister,et al.  The effect of insufflation pressure on pulmonary mechanics in infants during laparoscopic surgical procedures , 2003, Paediatric anaesthesia.

[15]  S. Eaton,et al.  Carbon dioxide elimination during laparoscopy in children is age dependent. , 2003, Journal of pediatric surgery.

[16]  J. Hunter,et al.  Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery. , 2002, Journal of the American College of Surgeons.

[17]  E. Steyerberg,et al.  Impact of carbon dioxide and helium insufflation on cardiorespiratory function during prolonged pneumoperitoneum in an experimental rat model , 2002, Surgical Endoscopy.

[18]  T. Miyano,et al.  Laparoscopic surgery in newborn infants , 1999, Surgical Endoscopy.

[19]  J. Tobias.  Anaesthetic implications of thoracoscopic surgery in children , 1999 .

[20]  E. Lucchinetti,et al.  Substantial Changes in Arterial Blood Gases During Thoracoscopic Surgery Can Be Missed by Conventional Intermittent Laboratory Blood Gas Analyses , 1998, Anesthesia and analgesia.

[21]  L. Spitz.  Esophageal atresia: Past, present, and future , 1996 .

[22]  D. Gunatilake.  Case Report: Fatal Intraperitoneal Explosion During Electrocoagulation via Laparoscopy , 1978, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[23]  A. A. El-Kady,et al.  Intraperitoneal Explosion during Female Sterilization by Laparoscopic Electrocoagulation , 1976, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.