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This lecture addresses the leadership roles in American surgery.

OBJECTIVE: The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD: One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). CONCLUSION: Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.

Questions persist about the management of postoperative chylothorax in infants and children. Our experience with postoperative chylothorax over the most recent decade (1980 to 1990) has been reviewed. The type and amount of drainage, data from cardiac catheterization and echocardiography, operative decisions and details, and eventual outcomes have been cataloged. All patients were initially treated with total gut rest, with operation reserved for unabated drainage. Chylothorax developed postoperatively in 15 infants and 11 children (18 with a cardiac procedure and 8 with a noncardiac procedure). The average age was 3.1 years. Spontaneous cessation and cure occurred in 19 (73.1%) of these 26 patients, with an average drainage duration of 11.9 days (range, 4 to 30 days). Those for whom operation was chosen drained preoperatively for an average of 29.2 days (range, 25 to 40 days). There were no deaths in either group. Complications were lymphopenia (2 patients) and fungal sepsis (1 patient). The amount of drainage per day was not significantly different between patients treated operatively and those treated nonoperatively. Failure of nonoperative management was associated with venous hypertension from increased right-sided cardiac pressures or central venous thrombosis (p < 0.05, Fisher's exact test). Presumably this increased pressure is transmitted to the lymphatic system. These patients should be identified early and considered for thoracic duct suture or pleuroperitoneal shunting.

It is controversial whether treatment with corticosteroids reduces stricture formation in the esophagus after the ingestion of caustic material.We conducted a prospective study over an 18-year period in which 60 children (median age, 2 years) with esophageal injury from the ingestion of caustic material were assigned randomly to treatment either with or without corticosteroids. The corticosteroids were given initially as prednisolon (2 mg per kilogram of body weight per day intravenously) and then as prednisone orally to complete a three-week course. All patients were evaluated by esophagoscopy within 24 hours of the ingestion. Those with moderate or severe esophageal injury had repeat esophagoscopy and barium swallow at follow-up.Esophageal strictures developed in 10 of the 31 children treated with corticosteroids and in 11 of the 29 controls (P not significant). Four children in the steroid group and seven in the control group eventually required esophageal replacement (P not significant). All but 1 of the 21 children with strictures had severe circumferential burns on initial esophagoscopy.There appears to be no benefit from the use of steroids to treat children who have ingested a caustic substance. The development of esophageal stricture was related only to the severity of the corrosive injury.

There are few pediatric illnesses as gratifying to diagnose and as immediately responsive to treatment as infantile hypertrophic pyloric stenosis (IHPS). Anxious parents can be reassured convincingly by the knowledgeable clinician who, upon hearing a suggestive history and with palpation alone, conclusively establishes a diagnosis and confidently recommends an invariably effective mechanical solution. An updated awareness of current evaluation and management of IHPS should be part of every pediatrician9s armamentarium. Real-time ultrasonography has moved into a dominant role in the evaluation of any infant suspected of having IHPS whose diagnosis cannot be confirmed by the characteristic history coupled with the classic feel of an olive-shaped mass in the right upper quadrant. X-ray study of the stomach with barium should be reserved for those select patients who present confusing or indistinct diagnostic features; it should not be ordered indiscriminately by the pediatrician who suspects IHPS. HISTORIC PERSPECTIVE Although the physical signs and symptoms of pyloric stenosis were described as early as 1717 in Europe and 1788 in America, it was not until 1887 that the pathology and clinical features of pyloric stenosis were described accurately by the Danish pediatrician Hirschsprung.1 Conservative treatment was attempted during the end of the 19th century but was rarely successful.

Trauma is the leading cause of death for children over 1 year of age. This study was undertaken to identify the patterns of injury among children admitted to a regional pediatric trauma center. During a 34-month period, 3,472 injured children were consecutively admitted to a regional pediatric trauma center. Data were collected on medical, etiological, and financial aspects of injury. Eight subgroups were defined by mechanism of injury: motor-vehicle crash occupants, pedestrian and cycle injuries, falls, child abuse, gunshot and stab wounds, burns, poisonings, and foreign body ingestions or aspirations. Analysis of variance, Duncan's multiple range test, and contingency table analysis were used to determine differences among subgroups of children. Blunt and penetrating trauma accounted for 64.3% of all admissions. The mean age of injured children was 5.5 years; 64% of the children were boys. Sixty-seven percent of the children were admitted directly from the scene of injury. One-way analysis of variance yielded significant differences in mean age, mean hospital length of stay (LOS), mean intensive care LOS, mean trauma score, mean injury severity, and mean hospital charges by mechanism of injury (P less than .01). The overall mortality rate was 2.4%. Child abuse, gunshot/stab wounds, and drowning had the highest mortality rates, but injuries to motor-vehicle crash occupants and pedestrians accounted for the greatest number of deaths.

Thirty-ine children and adolescents with a solitary nodule of the thyroid gland were seen over a 16-yr period and 35 had their nodules removed surgically. All of the patients had preoperative thyroid scintiscans, of which 27 showed a cold nodule. The most common cause of solitary thyroid nodules was follicular adenoma. Five of the 27 cold nodules were malignant (18.5%) while no malignancies were present in the warm or hot nodules. Available diagnostic methods of attempting differentiation of benign from malignant solitary nodules are reviewedd and an approach to the clinical management of such nodules as derived from our experience is presented.

Cloacal exstrophy, centered on the maldevelopment of the primitive streak mesoderm and cloacal membrane, results in bladder and intestinal exstrophy, omphalocele, gender confusion, and hindgut deformity. The surgical management and outcome of 10 of 14 survivors (1965 to 1988) are described. Genotypic males (6) were assigned male (2) or female (4) phenotype. Genotypic females (4) were unchanged. All had omphalocele closure in the newborn period. Two had loop stomas. Eight had end stomas (ileostomy [6], ileocolostomy [2]). Toddler and adolescent reconstruction differed in each. Early in the study, abdominoperineal pull-through failed in four patients, necessitating permanent stoma. Four patients had a stoma from the outset. Augmentation using colon remnant improved water loss and nutrition in two infants. Exstrophy turn-in for urinary reservoir was considered in all, but was impossible in three who required urinary diversion. Six patients had exstrophy turn-in and now void by clean intermittent catheterization (4), continent vesicostomy (1), and incontinent (1). Hindgut augmentation improved urinary capacity in two. Two genotypic-phenotypic males had penile lengthening. Four genotypic male-phenotypic females had early orchiectomy with subsequent clitoroplasty or vaginoplasty. Four genotypic-phenotypic females had clitoroplasty or vaginoplasty. Cloacal exstrophy is compatible with a useful life and sound psychologic development, but requires staged reconstruction with long-term support and follow-up.

A classification of vaginal anomalies has been derived, which permits logical operative decisions. This tool allows the assignment of increasingly involved reconstructive operations to progressively more complex vaginal anatomies. The outcome of this approach in 49 vaginal reconstructions performed in 36 patients over a 25-year period has been analyzed. The cause was found to be congenital adrenal hyperplasia in 21 patients, gonadal dysgenesis in four, and cloaca in two; nine children had other causes. Based on the following anatomic classification and the authors' clinical experience, the following approaches to reconstruction can be recommended. Eight infants with labial fusion (type I) underwent simple introitoplasty. Fourteen patients with distal urogenital sinus (type II) underwent flap vaginoplasty using labioscrotal tissue and/or a posteriorly based flap. Pull-through vaginoplasty was used in 10 children with distal vaginal atresia and proximal urethrovaginal fistula (type III). Four patients with absence of the vagina (type IV) required segmental colon vaginoplasty. Thirteen revisions have been required in nine patients thus far. The follow-up period is 1 to 17 years, and despite the need for reoperation, all but two patients have excellent or satisfactory results based on anatomic and functional considerations. The choice for and timing of vaginal reconstruction rests on precise anatomic evaluation. The complexity of vaginal reconstruction in the growing child and the essentiality of psychosocial adjustment to appropriate sexual identity and function mandate long-term comprehensive follow-up. Optimal care for each patient requires experience and continuity to take the child through diagnosis, surgical reconstruction, stressful adolescence, and into adulthood with full attention to anatomic, physiological, and psychological support.

Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.

The incidence of alkaline gastroesophageal reflux (GER) was examined in 111 consecutive children referred for evaluation of GER during a 1-year period. The results of 24-hour pH monitoring studies and the medical records were retrospectively evaluated. Acid reflux was defined as occurring whenever the pH was less than 4 and alkaline reflux was defined whenever the pH was greater than 7. The percentage of time that reflux occurred, the number of reflux episodes, the number of episodes greater than 5 minutes, and the longest episode were all recorded. Based on these data, four categories of patients were identified as compared with normal values as determined by Pellegrini et al. When using criteria based on the percentage of time that reflux occurred, the largest group of children with GER was found to reflux acid (50%). However, 27 children (24%) had combined acid and alkaline reflux. Eighteen (16%) had predominantly alkaline reflux. Previously, these 18 children would have been considered as having a low likelihood of reflux by pH criteria. Endoscopic examination showed that pathological evidence of esophagitis occurred in four of the children with pure alkaline reflux. This review shows that symptomatic GER in infants and children may be due to acid or alkaline secretions or a mixture of both. A previously unrecognized cohort exists of children who demonstrate primary alkaline reflux. These patients need to be recognized and may benefit from a therapeutic program specifically designed to control alkaline reflux.

RANSPLANTATION OF THE LIVER as an auxiliary organ has intrigued investigators for over a decade. The prime advantages of this procedure are the avoidance of the technically hazardous job of host hepatectomy and immediate and total dependence on homograft function as is required in orthotopic (replacement) transplantation. The functional reserve of the patient’s own liver may also permit survival during impaired homograft function subsequent to rejection crises. In addition, and particularly in children, the handicap of providing a comparable-sized organ is eliminated. The scarcity of donors of appropriate size has imposed severe limitations on the number 01 children able to have orthotopic transplantation. In auxiliary liver transplantation, advantage may be taken of the organ-donating potential of stillborns and newborn infants with anomalies incompatible with life. These features have prompted extensive laboratory investigation of hetero.. topic hepatic transplantation. It is now unequivocably established that portal inflow from the host splanchnic bed must be supplied to the homograft. Lack of such provision results in atrophy of the transplant and its consequent failure to support life. Unfortunately, the penalty for total diversion of portal blood to the graft is involution and impairment of the functional integrity of the native liver. The specific requirements for auxiliary liver transplantation have been, for the most part. worked out in the dog. Anatomically and physiologically the porcine liver more closely resembles that of the human than does the canine livet.‘.’ Furthermore, the privileged immunologic status reportedly3-5 enjoyed by orthotopic porcine liver homografts suggests that the pig would be a more suitable model for investigation of auxiliary transplantation since immunologic rejection might be less of an obscuring factor in subsequent physiologic analysis. Finally, the portal vein in the pig is unique in that separation of the common mesenteric vein from the portal vein is technically feasible. This permits selective redirection of the intestinal and pancreatic venous blood into either the transplant or host liver while the other liver in the dual system is perfused with gastric and splenic venous effluent. Thus, simultaneous, albeit constitutionally different, portal inflow may be provided to both livers. The purpose of this communication is to report our preliminary results with the “split” portalRow model of heterotopic hepatic transplantation in the pig. The specific fac~rorrr thr Surgical Research Lahomtor~. Researzh b‘oundaiion o/ the t‘hddren’,\ Hospital o/ th(, Di.7tric.t of’ Columbia. Washington. D.C and the Division of Pediatric, Stugerv. Departnwnt I)/ .SurServ. L,‘mversii!, of Colorado Medicul Center. Lknvrr. COLI.

The handling of trauma victims in the pediatric age group has undergone change and improvement in a number of ways. First, receiving facilities, emergency rooms, medical centers, and tertiary pediatric care facilities have all been brought together by community, state, regional, and national planning which has taken into account population needs and the resources of each facility. Communication by telephone, radio, and computerized information transmitters has linked together a series of medical facilities which now assures that each child is treated appropraitely or passed along to a different unit in the chain. The education of all members of the emergency medical services to the special techniques, equipment, and needs of pediatric patients has been essential to proper handling of injured children.

In the past 15 yr, 46 children have been seen because of disfiguring enlargement of the clitoris. Causes of clitoromegaly in these patients are: congenital adrenal hyperplasia, 23; maternal ingestion of hormones, 8; mixed gonadal dysgenesis, 3; true hermaphrodite, 2; male pseudohermaphrodite, 1; Stein-Leventhal syndrome, 1; and idiopathic, 8. In nine patients, particularly early in this experience, enlargement of the clitoris was so marked as to require complete surgical excision of the clitoris. Thirty-seven children have undergone a corrective procedure designed to restore feminine contours and to preserve sexual function. The operation involves recession of the enlarged organ beneath the pubis, reduction of the glans in selected instances, and reconstruction of the mons veneris. Recent evaluation of the patients has been undertaken with focus on: (a) appearance; (b) psychological adjustment; and, in the older patients, (c) sexual function. Results show that 27 patients are judged excellent; three are satisfactory; four patients were not available for follow-up study; eight patients have undergone a second operation. Three patients have an unsatisfactory outcome with persistant enlargement of the clitoris. One of the three required clitorectomy, another has thus far refused additional surgery, the third will undergo further correction later.

Several reports suggest that pediatric patients with stable liver injuries can be managed nonoperatively with few complications. From March 1978 to July 1983 seven children with hepatic injury were managed without surgery at CHNMC. Four children required greater than 50% total blood volume replacement, while the mean PRBC transfusion rate was 28 cc/kg. Eight major complications developed in five patients. Hospitalization averaged 23 days, without a mortality. This morbidity is greater than that described in earlier reports. In view of the limited cumulative clinical experience, we caution against routine nonoperative management of liver trauma in children until data with this new technique become available for analysis.

The Golden Lion Tamarin ( Leontopithecus rosalia ) is an endangered species of primate indiginous to the coastal rain forest of Brazil. Since 1971 a propagation and behavioral research program has been carried out on a colony of these monkeys at the Zoological Park. Several related animals have died and at necropsy have shown absence of the anterior portion of the diaphragm with a variety of abdominal viscera in the thorax. Diagnostic studies undertaken on the living members of the colony include plain chest radiographs and gastrointestinal series. Four of the animals have been found to have major diaphragmatic defects with the liver, stomach, spleen, colon, and portions of the intestine in the chest. In three of the animals so affected clinical signs of failure-to-thrive were clearly manifest, although one female born in 1968 has reproduced sucessfully for 8 yr with no deleterious clinical effects from the hernia. Surgical repair of the diaphragm with relocation of the abdominal viscera has been carried out in three of the animals under a combination of intravenous and intra-tracheal anesthesia. The monkeys weighed 550, 685, and 710 g, respectively. All three Tamarins have survived the operative procedure, and subsequently have shown improved clinical status. These cases have been instructive from the genetic point of view, the major anatomical defect, the type of repair necessary, and the postoperative care in small vigorous mammals. Additionally this study documents a familial factor in diaphragmatic defects in higher mammals.

A newborn with dysgenetic male pseudohermaphroditism associated with a gonadoblastoma is presented. The importance of differentiating this syndrome from other forms of male pseudohermaphroditism is emphasized.

Fifty-six patients with esophageal atresia and distal tracheoesophageal fistula (Vogt-Gross type C) have been treated at our institution since 1966. The methods of treatment have been individualized according to gestational age, birth weight, pulmonary status, and coexistence of other major anomalies. Three distinct approaches have evolved: Immediate primary repair is reserved for infants weighing more than 2 kilograms who have no major anomalies and satisfactory pulmonary status. Delayed primary repair is used in infants of adequate weight (more than 2 kilograms) who have significant but reversible pulmonary changes, with anticipated recovery within I week, and in those in whom several days are required for evaluation of an associated congenital anomaly; we temporize by upper pouch suction, gastrostomy, and antibiotics. Staged repair is used in premature and severely distressed infants as well as in those with cardiac lesions of surgical priority; staging consists of upper pouch suction, gastrostomy, retropleural division of the fistula, or gastric division, with subsequent transpleural repair in 4 to 8 weeks. The surgical approach to each of these infants has been selected after assessment of all aspects of their clinical condition. Flexibility in treatment, which is predicated upon previously established criteria, seems superior to any single surgical plan.

At the Children’s Hospital in Washington, D.C., 18 patients have been seen in the past 12 years with primary tumors of the liver. The tumors were divided as follows: 13 hepatoblastoma, 2 hepatocellular carcinoma, 2 rhabdomyosarcoma, and 1 mixed mesenchymal sarcoma. Of the patients with hepatoblastoma, all were seen by 4 years of age, and 8 were under 1 year when first seen. Three had pulmonary metastases when first seen. The 2 patients with hepatocellular carcinoma were 8 and 12 years old, respectively. The patients with embryonal rhabdomyosarcoma were 18 and 30 months of age when seen; 1 had a primary tumor arising in the liver, the other had a tumor in the bile ducts extending into the liver. Ten of the 13 children with hepatoblastoma underwent lobectomy; 5 of these 10 are alive, 1 with known metastases. The other 4 are presumed cured. One of the children with hepatic carcinoma had severe preexisting cirrhosis of the liver and has had 3 local limited excisions. One of the patients with rhabdomyosarcoma is alive and cured after hepatic lobectomy. As yet, there is no known effective chemotherapeutic regimen. Radiation therapy has been useful only in shrinking the tumor, but neither of these modalities has resulted in cure. At the present time, the only known cures are achieved by early detection and successful surgical removal.

Since 1966, 118 infants with esophageal atresia associated with tracheoesophageal atresia (Vogt-Gross Type C) have been operated upon with an overall survival rate of 90% at our institution. Since Haight's first survivor in 1941, argument has continued about the relative merits of immediate repair, delayed primary repair, and staged repair, and the criteria for selection of each approach. The Waterston classification served as the foundation for selection of surgical management from 1966 to 1982. Since 1982, physiologic status has been used as the sole basis for surgical management without regard to weight, gestation, or pulmonary condition. Twenty-six patients so chosen for immediate repair have all survived. Fewer have required gastrostomy, and the average hospital stay has shown significant decrease, a reflection of improved overall care of the neonate. Thirteen infants with severe cardiopulmonary compromise had some form of staged repair in this latter period with a 77% survival rate. Our experience using a refinement of Waterston's principles has led to more and earlier primary repairs with maintenance of excellent survival rates in stable infants. A staged approach is still useful for certain severely compromised infants.

Management of the pediatric patient sustaining a traumatic injury is influenced by patient size, surface area to body mass ratio, thermoregulation, and fluid requirements. A predetermined and systematic approach to the injured child guarantees recognition of life-threatening injuries and provides a method for rapid stabilization. The algorithm is divided into two distinct phases: life support and post-stabilization. The unique aspects of care of the injured child are highlighted to emphasize the significant differences in resuscitation and diagnosis from that of the adult patient.

In the past decade, seven children with the prune-belly syndrome have been seen. Their management has consisted of immediate high tubeless urinary diversion, usually pyelostomy. Thereafter, total reconstruction has been carried out, preferably at one stage. This consists of (1) bilateral shortening, tapering and reimplantation of the ureters, (2) reduction cystoplasty, (3) bilateral orchiopexy, and (4) excision of that part of the abdominal wall that is most redundant and least endowed with musculature. This early effort at mechanical reconstruction has led to gratifying progress in six of the seven children.

Thirty-one infants less than a year of age underwent surgery for correction of pernicious gastroesophageal reflux. Severe growth retardation from persistent vomiting was the single most important indication for surgery (25 patients). Recurrent aspiration penumonitis was another serious sequella of reflux and necessitated surgery in six patients. The diagnosis of gastroesophageal reflux was confirmed by barium swallow in all children, and in 17 a concomitant hiatal hernia was demonstrated. Patients selected for surgery were first treated conservatively unless they showed significant esophagitis or had a major portion of stomach in the chest. Babies treated early in the series had Allison repairs (7 transabdominal, 2 thoracic). Twenty-two subsequent patients have had Nissen fundoplication, and two gastropexies were performed. In 15 patients, significant gastric outlet obstruction required a complementary pyloroplasty. Four infants required a second surgical procedure because of recurrence. Two of the four patients had Nissen procedures with good results, one following a Boerema gastropexy and one following an Allison repair. The other two patients needed revision after fundoplication. There was no mortality. Twenty-eight children have been followed 6 months-8(1/2) years. All have excellent nutritional status and are following normal growth curves. Study of these patients indicates the need for early diagnosis and medical or surgical therapy for all infants with major gastroesophageal reflux.

UNLABELLED In the past 15 years at Children's Hospital in Washington, D.C., approximately 500 infants under 1 year of age have been evaluated because of symptomatic gastroesophageal reflux. A contrast esophagogram will demonstrate reflux in the majority of affected infants. However, this diagnostic method is not always reliable. Timed monitoring of esophageal pH, and extended radionuclide scan even in infants can document accurately the frequency and character of episodic reflux. Following diagnosis, most infants are treated by conservative therapy, which includes the upright position. Of the 500 patients, 72 infants (14%) were selected for operative correction using the Nissen fundoplication. The indications for surgery in these infants with gastroesophageal reflux were: (A) failure to thrive, (35); (B) chronic respiratory infection, (24); (C) apnea spells, (8); and (D) esophagitis. One infant was found to have a stricture. In these symptomatic patients, three had previous operative correction of esophageal atresia, and two had congenital gastric dislocation in the chest. RESULTS 61 excellent; six recurrences, of whom five are satisfactory after a second operation; two lost to follow-up but doing well when last seen; three deaths from causes unrelated to reflux. The selection of infants with gastroesophageal reflux for surgical correlation is primarily based on life-threatening clinical effects. The Nissen fundoplication has worked well in this group of infants.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.

Aerobic and anaerobic bacterial flora of burn sites in 180 children were monitored. Specimens were obtained twice a week; each patient had between one and 21 cultures taken (mean 2.4). A total of 392 specimens were collected over 2 years, of which 319 were positive. Aerobic bacteria alone were present in 225 specimens (71%) and anaerobic bacteria alone were present in 26 (8%). Mixed aerobic and anaerobic bacteria were present in 68 burn specimens (21%). A total of 580 isolates (448 aerobes and 132 anaerobes) were recovered, accounting for 1.8 isolates per specimen (1.4 aerobes and 0.4 anaerobes). The predominant aerobic isolates were S. epidermidis, S. aureus, alpha hemolytic streptococcus, Pseudomonas sp., and Group D streptococcus. The predominant anaerobic isolates were: P. acnes, anaerobic Gram-positive cocci, and Bacteroides sp. Blood cultures were drawn from 45 children: four showed bacterial growth of one of each of the following isolates: S. aureus, E. coli, Peptococcus asaccharolyticus, and B. fragilis. The numbers of isolates per specimen were higher in the oral and anal area (3.2 and 2.8) than in the extremities and trunk (1.8 and 0.9). Gram-negative enteric rods and Group D streptococci were more frequently recovered from the anal area. S. aureus, S. epidermidis, and P. acnes were more frequently recovered from extremities. Bacteroides sp. and Fusobacterium nucleatum were more frequently recovered from the anal and oral areas. All children were treated with local application of silver sulfadiazine, and antimicrobial therapy was used in 128 children. Statistical analysis showed no correlation between the bacteria isolated and use of antimicrobial agents. These data suggest a role for anaerobic bacteria in the colonization of burns in children, especially in burns of the anal and oral areas.

Tumors of the liver are uncommon in children. It is imperative that surgeons caring for these patients have a knowledge of the likely diagnosis, proper radiographic evaluation, and appropriate selection and extent of surgical therapy. Of the benign lesions, infantile hemangioendothelioma often is best treated nonoperatively, whereas mesenchymal hamartoma and teratoma should be resected. All malignant lesions must be completely excised to cure the patient, but some may be converted from unresectable tumors to resectable ones by preoperative chemotherapy. Major hepatic resection is one of the most formidable procedures in the surgery of children. Careful preparation, attention to technical detail, and precise postoperative management of the critically ill child are prerequisites for success. For a recent review of the extrahepatic biliary tract problems of infants and children, the reader is referred to the article by Stolar and Altman in Surgical Clinics of North America, Volume 65, October 1985.

Burns constitute a major cause of childhood death and disability. Prevention of these injuries remains the most effective method of dealing with them and is the responsibility of all persons caring for children. Despite all therapeutic advances, 3% of children admitted to our burn unit die of their injury; many more suffer significant physical and psychological morbidity. Care for these patients is best provided by a multidisciplinary unit with many professionals working together as a team from the day of injury until the child reaches adulthood.

The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.

BILIRUBIN metabolism and excretion in children with biliary atresia is complex and poorly understood. Jaundice may not be apparent until the infant is three or four weeks of age. Rarely, as in a case reported by Sterling,1 the jaundice disappears, and for weeks the serum bilirubin levels are normal. Usually, however, the serum bilirubin levels continue to rise for several weeks after birth and thereafter remain relatively stable. Like the normal infant, the child with biliary atresia is continuously producing bile pigment from the breakdown of hemoglobin. Since the serum bilirubin levels do not continue to rise one must assume . . .

There is constantly a better understanding of the variety of congenital malformations of the genitalia which comes under the heading of intersexual abnormalities. Prompt recognition of these anomalies can now lead to correct sex assignment shortly after birth, minimizing the anatomical, psychological and social problems for these individuals in later life. For female babies born with an enlarged clitoris, total clitorectomy has become an established procedure. It has been shown that the clitoris is not essential for adequate sexual function, but its preservation would seem to be desirable if this could be achieved while maintaining satisfactory appearance and function. Operations to reduce or cover the enlarged clitoris without removing it have been suggested in the past, 1–3 Certain drawbacks of these procedures have prompted our search for a surgical technique which would preserve the clitoris in its anatomical position, yet permit the reconstruction of normal female contours during the important growing years of childhood. An operation has been devised which we believe meets these requirements. Our experience with this procedure over the past five years and its postoperative evaluation in female patients is reported here.

IN the recent literature considerable attention has been paid to recognition and management of obstructions at the bladder neck in children. This condition is relatively uncommon when compared to the numerous other anomalies of the urinary system, but it is highly important to detect, since it can insidiously lead to extensive destruction of kidney and excretory tracts. It is now known that the institution of appropriate therapy can effectively ward off renal damage and minimize superimposed infection. The entity has been recognized and described for decades, but it has not come into focus until the past few years. In 1915 . . .

1. A method of gastric analysis has been developed for the study of newborn infants. Results obtained with this method have shown it to reflect more accurately the ongoing secretory activity of the stomach. Previous methods of sampling left significant and varying amounts of acidity behind in the stomach rendering much of the available data inconclusive. 2. For the first time, gastric function has been correlated with specific disease states in the infant. 3. The volume, pH, total acidity, chloride content, and pepsin activity have been found to vary independently of one another. 4. Pneumonia and bronchiolitis, two conditions producing compromised respiratory function, were characterized by decreased total acidity, a more alkaline pH, and decreased pepsin activity. 5. Infants with short gut after bowel resection displayed highly significant increases in total gastric acidity and rate of acid formation, and a lower gastric pH. 6. Infants with acyanotic congenital heart disease showed significantly decreased pepsin content and increased chloride concentration despite normal acidity. Conversely, the few infants with cyanotic congenital heart disease studied had decreased volume of gastric juice and rate of acid formation.

Twenty infants with intractable diarrhea, whose onset was before 3 months of age, were analyzed. Twelve had identifiable pathological entities sufficient to explain their protracted diarrhea. A systematic diagnostic scheme for such babies is presented. Eight of the 20 infants had no identifiable cause for diarrhea of such severity and refractoriness, and these babies were termed non-specific enterocolitis. Six of these latter eight babies died and at autopsy had widespread enterocolitis with destruction of the mucosa and inflammatory infiltration. The authors believe that in these latter cases, regardless of the initial cause of the diarrhea, certain vicious cycles came into play which perpetuated the diarrhea. Preliminary evidence suggests that colostomy and, perhaps adrenal corticosteroids, may be useful in the therapy of refractory enterocolitis, particularly if applied before the terminal stages of the disease.

A clinical staging of patients with neuroblastoma is proposed. Such staging is desirable to aid in estimating the prognosis and to be able to evaluate the efficacy of differing therapeutic regimens by analyzing results obtained in comparable groups of patients. That the suggested staging is practical is illustrated by the ease with which 100 children with neuroblastoma, entered in previous studies by Children's Cancer Study Group A, were staged using the criteria described. Short-term survival data of this small sample demonstrated, in addition, that the proposed staging appears to be of help in estimating the prognosis. Also proposed is a list of investigations which aid in accurate staging.

The treatment of 27 infants presenting with omphalocele or gastroschisis was analyzed. Several different methods of therapy were available, but various treatment plans were chosen on an individual basis. The defects were classified according to the size of the anomaly, the presence or absence of sac rupture, and the presence of coexisting abnormalities. Infants with intact omphalocele sacs less than 5 cm in diameter were best treated by surgical closure of the musculofascial defect or by skin closure alone. Intact omphaloceles over 5 cm in diameter or those associated with other life-threatening anomalies were treated conservatively with local applications of mercurochrome. Ruptured omphalocele or gastroschisis required immediate surgical coverage. If skin closure was not possible, a plastic prosthesis of Silastic covered Marlex was useful as a temporary cover for the exposed intestine. Infectious complications from the exposed prosthesis were minimized by the use of 0.5% silver nitrate dressings. An overall survival rate of 70% was obtained using the most appropriate treatment plan for the particular anomaly.