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During the 37 year period between 1943 and 1980, 68 pediatric patients underwent 86 major pulmonary resections during 73 separate operations. The surgical procedures included lobectomy (55), segmentectomy (25), pneumonectomy (three), and cyst excision (three). The 73 operations were performed for nontuberculous infection, congenital malformation, tuberculosis, tumor, obstructive lung disease, cardiac-related problems, immunologic disease, and trauma in decreasing order of frequency. The operative mortality was 4.4%; the disease-related late mortality was 6.2%, due to either chronic respiratory failure or metastatic disease. Complications occurred in 21.9% of the operations. Only one death occurred during the last two decades, but the morbidity rate remained constant through all decades. Analysis by decade showed a striking change in the spectrum of pediatric pulmonary operations over the 37 year study period. Three major trends were identified: (1) Bronchiectasis and tuberculosis, once the major indications for pulmonary resection, have, from a surgical standpoint, virtually disappeared. (2) Congenital pulmonary anomalies now account for the majority of major pediatric pulmonary resections. As a consequence, the patient age at operation has steadily decreased, and pulmonary resections in infants (under 1 year of age) make up almost half of the surgical resections currently being done. (3) Despite the marked decline in the number of operations performed for infectious pulmonary disease, the total number of pulmonary operations in the pediatric age group has not decreased.

The authors describe biliary atresia as a progressive, panductular, obliterative disease process that probably begins in utero. Biliary obstruction can be relieved in many infants under three months old by amputation of the extrahepatic bile ducts and substitution of an intestinal or gallbladder conduit. Despite complications of cholangitis, portal hypertension, and fat-soluble vitamin deficiencies, the current five-year survival rate is 59 per cent.

Currently, no single area in pediatric surgery arouses more heated controversy than does the surgical treatment of biliary atresia. Because of reports (few have been published) of spontaneous resolution of biliary atresia, only limited operations have been recommended to avoid damage to unrecognized ductal structures. Conversely, because of other reports of correctable lesions "missed" at operation and subsequently discovered at autopsy, a thorough surgical exploration has been urged. The dilemma has not been helped any by communications from Japan about another operation for biliary atresia in which the extrahepatic bile ducts are removed entirely.For a while, most American pediatric surgeons simply ignored the Japanese communications. This action, or lack of action, was subsequently believed fully justified after the initial pessimistic report in the United States by Campbell and associates.1 After experiencing ten outright failures in ten successive patients, the authors legitimately concluded "... that hepatic portoenterostomy appears

Treatment of vitamin E deficiency during chronic childhood cholestasis is hampered by the poor intestinal absorption of available oral preparations of vitamin E when bile flow is severely impaired; thus parenleral vitamin E has been the only effective therapy for many children with this problem. We studied the intestinal absorption, efficacy, and safety of a water-soluble oral form of vitamin E, d-α-tocopheryl polyethylene gjycol 1000 succinate (TPGS), in 22 children (7 mo to 19 yr old) with severe cholestasis and vitamin E deficiency who were unresponsive to massive oral doses (100–200 IU/kg · day) of dl-α-tocopherol. The results of oral vitamin E tolerance tests showed that TPGS was well absorbed in virtually all study subjects, that TPGS intestinal absorption was superior to that of dl-α-tocopherol, and that TPGS absorption in teenage children with chronic cholestasis was similar to that of normal adults. In addition, 1.7% ± 1.6% (mean ± SD) of the administered polyethylene glycol 1000 contained in the TPGS was absorbed and excreted in the urine of the 13 subjects analyzed, compared with 3.0% ± 1.3% in 4 normal adults. A chronic oral dose of 15–25 IU/kg · day of TPGS corrected the biochemical vitamin E deficiency state over 1–19 mo (mean, 10.6 mo) of TPGS therapy. No clinical or biochemical evidence of gastrointestinal, renal, hepatic, or hematologic toxicity was demonstrated. This study suggests that TPGS administered orally in a dose of 15–25 IU/kg · day may be a safe and effective form of vitamin E for prevention and correction of vitamin E deficiency during severe childhood cholestasis.

• Congenital right posterolateral (Bochdalek's) diaphragmatic hernia usually has clinical manifestations different from those of left Bochdalek's hernia; it often masquerades as a pleural effusion, an asymptomatic intrathoracic mass, or an intestinal obstruction. The primary reason for the difference in symptoms is the presence of the liver on the right, which occludes the diaphragmatic defect and permits normal development of the ipsilateral lung. We recommend a transabdominal approach for surgical repair.(Arch Surg 1982;117:341-344)