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Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery., Methods: A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR)., Results: LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge., Conclusions: Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB., Type of Study: Prognosis study LEVEL-OF-EVIDENCE RATING: Level II., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB)., Methods: In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR)., Results: The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation., Conclusions: The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital., Level-Of-Evidence: Level II., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE)., Methods: A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications., Results: LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group., Conclusions: INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.

Introduction: Cloaca malformation repair strategy is strongly dictated by common channel and urethral lengths. Mid to long common channel cloacas are challenging and often require laparotomy for dissection of pelvic structures. The balance of common channel and urethral lengths often dictates the approach for reconstruction. Laparoscopy has been utilized for rectal dissection but not for management of the urogenital (UG) structures. We hypothesized that laparoscopy could be applied to UG separation in reconstruction of cloaca malformations. Methods: Records were reviewed for 9 children with cloaca who underwent laparoscopic rectal mobilization and UG separation. Clinical parameters reviewed included demographics, relevant anatomic lengths, operative duration, transfusion requirements, and perioperative complications. Results: Repair was perfomed at a median (interquartile range) age of 12 (7, 15) months. Common channel length as measured by cystoscopy was 3.5 (3.3, 4.5) cm. There were no intraoperative complications. Transfusion requirements were minimal. Postoperative length of stay was 6 (5, 11) days. One patient developed a urethral web and 2 developed vaginal stenosis. One patient later underwent a laparotomy for obstruction due to a twisted rectal pull-through. Conclusions: Laparoscopic rectal mobilization and UG separation in long common channel cloaca are safe and well tolerated. Laparoscopy affords full evaluation of Mullerian structures and enables separation of the common UG wall, which may ultimately enhance long-term urinary continence.

Background: Morgagni hernias are rare, with a reported incidence of 2% to 5% of congenital diaphragmatic hernias., Objectives: To review a laparoscopic technique to repair Morgagni hernias in pediatric patients., Methods: Retrospective chart review of pediatric patients who underwent minimally invasive repair of a Morgagni hernia from November 2009 to September 2017 within a defined population., Results: During an 8-year period, 15 patients with Morgagni hernias were identified. Four patients with Morgagni hernias were excluded because they had open repairs. Eleven Morgagni hernias were repaired through a completely minimally invasive approach. Three repairs were completed using a soft-tissue patch (Gore-Tex patch, W L Gore & Associates Inc, Flagstaff, AZ). All minimally invasive repairs were completed with transfascial sutures using an endoscopic suturing device (Endo Close, Covidien/Medtronic, Fridley, MN) and 2-0 nonabsorbable synthetic sutures with extracorporeal knot tying. Median follow-up was 40 months (range = 2.6 months to 7.3 years). No patients had postoperative pectus excavatum defects. There were no recurrences., Conclusion: Morgagni hernias are amenable to minimally invasive repair with this simple technique. With large defects, synthetic patches should be used. Recurrences are rare, and morbidity is low.

Background: Reconstruction of complex chest wall deformities is a surgical challenge. A new technique can improve long-term outcomes and result in high patient satisfaction., Methods: A multicenter study was conducted on pediatric patients undergoing complex chest wall reconstruction between September 2015 and January 2018. The evolution of the technique using open reduction and internal fixation (ORIF) with SternaLock® and RibFix® to repair chest wall deformities is described., Results: Seventeen patients underwent complex chest wall reconstruction with ORIF. Eight patients had severe or recurrent pectus excavatum, five patients had pectus carinatum, and four patients had complex chest wall fractures or other anomalies causing significant chronic pain. Up to three SternaLock® plates and four RibFix® plates were used for each procedure. Median length of hospital stay after surgery was four days. Median follow-up time was 12 months (range 2-30). There were no postsurgical complications. There was 100% patient satisfaction in postoperative recovery and cosmesis., Conclusion: ORIF using SternaLock® and RibFix® is an effective method of reconstructing complex chest wall deformities. This technique improves physical stability without the requirement of a subsequent surgery and enhances overall patient satisfaction. High volume centers should integrate this novel approach for challenging chest wall reconstruction., Type of Study: Treatment study: case series., Level of Evidence: Level IV., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: The ability to use detailed, accurate current procedural terminology (CPT) codes is a key component of effective research. We examined the effectiveness of CPT codes to accurately reflect care in patients undergoing surgery for necrotizing enterocolitis (NEC)., Methods: A multicenter retrospective analysis of operations on patients with NEC was conducted across 4 institutions between 2011 and 2016. Correlation between operative dictation and CPT coding was analyzed., Results: A total of 124 patients with NEC diagnosis undergoing exploratory abdominal operations were identified. NEC was improperly diagnosed in 25 patients, who were excluded from further analysis. Of the 99 patients reviewed, the initial exploratory abdominal operation was coded inaccurately in 58 cases (59%). Within these, 15 (26%) had multiple coding errors such that the nature of the original operation was not discernable from the applied codes. Inaccurate codes often did not describe the presence of a mucous fistula (n=27, 44%), ostomy (n=24, 39%), or extra segments of bowel resected (n=9, 16%). The length of bowel resected is not currently described by any CPT codes., Conclusion: CPT coding for abdominal operations does not sufficiently reflect complexity of pediatric surgeries. This study highlights the significance of this inadequacy and its implications in future database studies in the era of electronic medical records., Level of Evidence: Level IV., Type of Study: Clinical research study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder affecting central control of breathing. Thus, patients require lifelong assisted ventilation. Diaphragm pacing (DP) may permit decannulation in those who are ventilator dependent only during sleep., Objective: The purpose of this study is to determine if patients with CCHS can be successfully ventilated by DP without tracheostomy., Methods: We reviewed the records of 18 CCHS patients (mean age 19.5 ± 10.1 years; 44% female) who were ventilated by DP only during sleep., Results: Prior to diaphragm pacer implantation surgery, 14 CCHS patients had been using home portable positive pressure ventilation (PPV) via tracheostomy, 1 had been on PPV via endotracheal tube, and 3 had been using noninvasive PPV (NPPV). Of the patients with tracheostomy prior to DP (n = 15), 11 (73%) were decannulated and ventilated successfully by DP without tracheostomy. Of all the patients reviewed (n = 18), 13 (72%) were successfully ventilated by DP without tracheostomy. Obesity prevented successful DP without tracheostomy in 1 patient, and upper airway obstruction prevented success in another patient. Snoring and/or obstructive apneas were present in some patients, but they were improved by diaphragm pacer changes, adenotonsillectomy, and/or use of nasal steroids., Conclusions: DP without tracheostomy can be successfully achieved in patients with CCHS. Snoring and obstructive apneas, when present, can be managed by diaphragm pacer changes and medical therapies. Obesity can pose a challenge to successful DP., (© 2015 S. Karger AG, Basel.)

Recurrent gastroesophageal reflux is a common complication after fundoplication procedures. We report our experience with laparoscopic redo Nissen fundoplications in pediatric patients with a history of open antireflux procedure. The medical records of all patients with a history of open antireflux procedure who underwent a subsequent laparoscopic redo Nissen fundoplication were reviewed. One hundred eighty laparoscopic Nissen fundoplications were performed between September 2004 and September 2012; 23 were redo procedures. Twelve patients had a history of prior open fundoplication. Average time between operations was 113.7±64 months. Seven patients presented with emesis, 4 with aspiration pneumonia, and 1 with clinical reflux. Eight had a history of cerebral palsy and/or seizure disorder. Laparoscopic revision was completed in 100% of the patients, with no intraoperative complications. Average operative time was 177.5±86 minutes. Seven patients were able to resume feeds on postoperative Day 1. Median length of stay was 3 days. Median follow-up was 21 months. One patient required a redo antireflux procedure 8 months later for persistent dysphagia. Thus laparoscopic revision Nissen fundoplication after a prior open antireflux procedure is feasible and safe.

Background/purpose: Choledocholithiasis is uncommon in the pediatric population. Techniques for common bile duct stone extraction are still not well established. This article aims to describe safe and applicable techniques for pediatric common bile duct exploration., Materials and Methods: This was a retrospective review of a prospectively maintained database of two pediatric surgeons for patients undergoing laparoscopic common bile duct exploration at two tertiary-care centers from April 2008 to March 2012., Results: For 39 patients under 15 years of age undergoing laparoscopic cholecystectomy, 10 cholangiograms were performed, and 8 were found to have filling defects. Seven patients underwent successful laparoscopic common bile duct exploration with documentation of stone clearance, and 1 patient was sent for postoperative endoscopic retrograde cholangiopancreatography with stone extraction. Eleven patients had cholecystectomy performed by single-incision laparoscopic surgery, but none of these had cholangiograms or common bile duct explorations. Various methods of stone clearance were used, including the use of saline flush, balloon catheters, nitinol stone extractors, and the aide of glucagon. Depending on patient size, a choledochosope or a ureteroscope was used. There were no complications and no conversions to open surgery., Conclusions: Laparoscopic common bile duct exploration is feasible in the pediatric population, using many of the instruments readily available in the standard operating room. With an armamentarium of tools and techniques, the method of stone extraction can be tailored to the patient and situation.

Context: Increasing popularity of strong magnets as toys has led to their ingestion by children, putting them at risk of potentially harmful gastrointestinal tract injuries., Objectives: To heighten physician awareness of the potential complications of magnetic foreign body ingestion, and to provide an updated algorithm for management of a patient who is suspected to have ingested magnets., Design: A retrospective review of magnet ingestions treated over a two-year period at our institutions in the Southern California Permanente Medical Group. Data including patient demographics, clinical information, radiologic images, and surgical records were used to propose a management strategy., Results: Five patients, aged 15 months to 18 years, presented with abdominal symptoms after magnet ingestion. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy. Total days in the hospital averaged 5.2 days (range = 3 to 9 days). Average time to discharge following surgery was 4 days (range = 2 to 7 days). Ex vivo experimentation with toy magnetic beads were performed to reveal characteristics of the magnetic toys., Conclusions: Physicians should have a heightened sense of caution when treating a patient in whom magnetic foreign body ingestion is suspected, because of the potential gastrointestinal complications. An updated management strategy is proposed that both prevents delays in surgical care and avoids unnecessary surgical exploration.

The hepatic portoenterostomy (HPE) is the accepted initial operation for biliary reconstruction for biliary atresia, but in a select group of patients with patent distal extrahepatic bile ducts (PDEBD), a hepatic portocholecystostomy (HPC) may also be considered. A10 year old boy presented with sudden onset of jaundice following a successful HPC at 2 months of age. Radiographic evaluation revealed excretion into a distended gallbladder with distal biliary obstruction. He underwent a successful Roux-en-Y cholecystojejunostomy and remains jaundice-free two years later. Cholecystojejunostomy is an effective salvage operation for patients who develop late distal biliary obstruction after an HPC., (Copyright © 2013 Elsevier Inc. All rights reserved.)

In children, pyogenic granulomas are most commonly cutaneous benign vascular lesions but can also present in the gastrointestinal tract. When they occur in the intestine, they can cause acute or chronic gastrointestinal bleeding. We present an unusual case of rectal pyogenic granuloma and our management strategy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Ultrasound guidelines for hypertrophic pyloric stenosis (HPS) have fixed minimum measurements and do not account for variation in patient weight or age. We sought to determine if preoperative pyloric measurements correlated with weight and age in patients with surgically proven HPS., Methods: A retrospective analysis was conducted of 189 patients with HPS treated at a single institution over a 5-year period (2005 to 2010). Pearson correlation and linear regression analyses were used to determine if there were statistically significant associations between these combinations of factors: age and pyloric muscle thickness, weight and pyloric muscle thickness, age and pyloric length, and weight and pyloric length., Results: Patients' mean age was 4.6 weeks (range, 1 to 17 weeks). Their mean weight was 3.9 kg (range, 2.5 to 8.0 kg). Mean pyloric muscle thickness was 0.42 cm (range, 0.18 to 0.86 cm), and mean pyloric length was 1.89 cm (range, 0.8 to 2.8 cm). Pearson correlation coefficient analysis showed a significant relationship between age and muscle thickness (r = 0.35, p < 0.001) as well as weight and muscle thickness (r = 0.24, p = 0.001). No significant relationship existed between pyloric length and age or weight. Linear regression analysis demonstrated similar results., Conclusion: In patients with HPS, pyloric muscle thickness was directly related to age and weight. Practitioners should be aware that smaller and younger infants with a clinical diagnosis of HPS may still truly have HPS even though the minimum diagnostic criterion for muscle thickness or length is not found on ultrasound.

We present a case of an adolescent with lower gastrointestinal bleeding caused by a colorectal venous malformation (VM) with concomitant portal hypertension. After an episode of massive gastrointestinal bleeding, we performed an extended right hemicolectomy and resection of the VM and selective portosystemic shunt. Here, we present the case and review the literature regarding portal hypertension and gastrointestinal vascular malformations. Additionally, we discuss the physiologic and hemodynamic effects of gastrointestinal vascular malformations on the portal system.

Prune belly syndrome (PBS), megacystis-microcolon-intestinal hypoperistalsis (MMIH), and omphalocele-exstrophy of the bladder-imperforate anus-spine abnormalities complex (OEIS) are rare congenital malformations of the newborn that lead to incomplete formation of the gastrointestinal and genitourinary tract systems. To date, incomplete mesodermal development is identified as the cause for all these complex genetic syndromes even if the etiology is still unknown. We present an original case sharing characteristics common to PBS, MMIH, and OEIS complex, without a clear inclination toward any particular one. This case hints toward a common pathway in the creation of the 3 syndromes. We hypothesize that they are a spectrum of malformations based on the time frame when the mesoderm fails to create a normal interaction between infraumbilical mesoderm, urorectal septum, lumbosacral somites in the formation of the abdominal wall and the genitourinary and lower gastrointestinal tracts., (Published by Elsevier Inc.)

Purpose: Inguinal hernias in infants and children may not be evident during visits to the pediatric surgeon's office. Preoperative photographic confirmation of the hernia may be helpful and accurate. This study retrospectively assesses the preoperative examination, photographic evidence, operative findings, and complications of these patients., Methods: For a 30-month period, children with a history of a possible inguinal bulge were assessed by clinical examination. If no bulge was detected, the parents were given the option of sending a photograph to the surgeon. Patients underwent surgery based solely upon the history and definitive image., Results: For 30 months, 25 children were evaluated for inguinal pathology but had no hernia on clinical examination. Based solely upon the history and the digital image, 23 of these patients underwent surgery. All of the patients who were diagnosed with a hernia by history and imaging alone had an operatively confirmed hernia. The remaining 2 patients have not developed a hernia with continued observation., Conclusion: Photographic images are a reliable way to document the presence and laterality of inguinal hernias. Reliance upon digital transmission of images avoids the need for repeat office visits, saving considerable physician and parental time and expense.

Background: Prenatal closure of the umbilical ring in gastroschisis may result in an amorphous, nonviable appearing extracorporeal tissue that is resected during the repair. However, it is unclear whether such remnant intestine is truly nonviable., Methods and Results: We examined the outcomes of patients when this tissue is preserved. We identified 8 patients who presented with a closing gastroschisis and a mass of tissue connected by a vascular pedicle. Four patients underwent abdominal exploration with resection of the mass and gastroschisis closure. Histologic examination revealed normal intestinal wall architecture. All patients in this group developed short bowel syndrome, requiring long-term parenteral nutrition. Conversely, 4 patients underwent abdominal exploration with internalization of the remnant tissue, a maneuver referred to as "parking," along with either silo placement, or primary closure of the gastroschisis. At re-exploration, 3 of 4 patients were found to have viable intestine, and bowel continuity was reestablished. The mean parenteral nutrition requirement for this group was significantly shorter than the resected group., Conclusion: In this series, we show that this amorphous tissue, when preserved, may exhibit normal intestinal architecture and absorptive function. Therefore, such remnant tissue should be preserved as it may significantly increase bowel length and minimize parenteral nutrition requirement.

Introduction: Thoracoscopic total pneumonectomy has not been previously described in the pediatric surgical literature. In this paper, we describe a case of pneumonectomy performed through a minimally invasive approach in a 9-year-old female with Down's syndrome and gastroesophageal reflux disease., Case Report: The patient suffered from multiple recurrent aspiration pneumonias, which progressed to bronchiectasis of the entire left lung. As a result, the patient was hypoxemic and required continuous supplemental oxygen. Preoperative perfusion scans showed diminished perfusion of the left lung. Thoracoscopy was performed by using 3-5 mm trocars and one 12-mm trocar. Insufflation pressure was maintained at 5 mm Hg. Dissection was performed at the hilum by using hook electrocautery and the LigaSure device (ValleyLab, Boulder, CO). The pulmonary artery, veins, and left mainstem bronchus were sequentially divided by using a 35-mm ENDO GIA vascular stapler (Ethicon Endo-Surgery, Cincinnati, OH). There were no intraoperative complications. Eight months following surgery, her health is improved and she no longer requires supplemental oxygen., Conclusion: Thoracoscopic pneumonectomy is a safe, technically feasible approach for severe bronchiectasis in children.

Purpose: Lipoblastoma is a rare, benign, adipose tissue tumor. We report the largest single institution experience managing these uncommon neoplasms., Methods: We retrospectively reviewed 32 cases of lipoblastoma entered in the pathology database at our institution between January 1991 and August 2005. We conducted a comprehensive literature review of lipoblastoma and summarized the results of the largest series published., Results: Most patients presented with an enlarging, palpable, firm, nontender, mobile mass. The male-to-female ratio was 1.9:1. The anatomical distribution was trunk (n = 12), extremity (n = 12), groin (n = 5), and neck (n = 3). Average age at resection was 2.8 years (range, 2.6 months to 12 years). Thirty-one cases were completely excised, although 1 patient underwent staged partial excision to preserve nerve function. Chromosomal analysis performed in selected patients revealed characteristic aberrations in chromosome 8. Complications included keloid formation (n = 3), wound infection/dehiscence (n = 2), wound seroma (n = 1), and transient brachial plexus neurapraxia (n = 1). Average follow-up was 7.4 months (range, 1 day to 6.5 years); 2 patients were lost to follow-up. There were no recurrences., Conclusions: A staged approach with meticulous sparing of the neurovascular bundle provides excellent functional outcome for patients with large tumors. Nonmutilating surgical excision is the treatment of choice.

Background/purpose: The aim of this report is to assess the technique and outcome of laparoscopic partial nephrectomy in infants and toddlers., Methods: From January 2001 to January 2005, 7 consecutive patients, ages 5 to 15 months, underwent laparoscopic partial nephrectomies. All patients had duplicated systems associated with ureteroceles (5), severe reflux (1), ectopic ureter (1), and nonfunctioning systems. Follow-up ranged from 4 to 51 months., Results: All procedures were completed successfully using 4 ports (2 x 5 and 2 x 3 mm) except one, which required an additional port. The distal ureter, renal parenchyma, and hilar vessels were all transected using the harmonic scalpel. The mean operating time was 179 minutes with minimal blood loss in each case. The average hospital stay was 2.4 days (range, 1-5 days). The first case in the series, initially attempted retroperitoneally, was converted to a transabdominal approach because of lack of space. All subsequent approaches were transabdominal. One patient required ureteral stump reexcision because of frequent urinary tract infections associated with a distal ureteral diverticulum., Conclusions: Laparoscopic partial nephrectomy can be performed safely. The harmonic scalpel divides the parenchyma bloodlessly. The cosmetic result is excellent. A transabdominal approach with division of the ureteral cuff flush with the bladder is recommended.

Background: The aim of this study was to review the outcome of surgical management of various types of perineal masses encountered in patients with anorectal malformations (ARM)., Methods: Retrospective review from 2 large pediatric anorectal referral centers., Results: Twenty-two patients with a perineal mass were identified in more than 2000 patients treated for an ARM over a 15-year period. The 22 patients (4 men) represented all levels of severity of ARMs. The lesions were of 3 types: lipomas (n = 10), vascular anomalies (n = 4), and hamartomas/choristomas (n = 8). The lipomas were carefully removed from between the muscle fibers during the posterior sagittal anorectoplasty. The vascular anomalies (3 of 4 were hemangiomas) underwent magnetic resonance imaging preoperatively, but none were found to invade deeply and all were excised at the time of the posterior sagittal anorectoplasty. The hamartomas/choristomas all occurred in women, and 50% arose as a pedunculated mass from the vulva. The lesions contained tissues such as glia, osteoid, nephrogenic rests, and endocervical-type mucosa. One was initially misinterpreted as a teratoma, prompting a wider excision. This and all subsequent patients have been correctly diagnosed pathologically as having either hamartomas or choristomas, which were not widely excised. Follow-up ranges from 5 months to 12 years. Six of the 10 lipoma patients are continent. One vascular anomaly was re-excised and there was minor wound separation in another. None of the hamartoma/choristoma lesions recurred., Conclusion: The presence of unusual perineal masses can add to the complexity of ARMs; however, most of these lesions can be carefully excised with preservation of the muscle complex and ultimate continence. Hamartomatous lesions can be mistaken for teratomas but do not require aggressive excision with clear margins.

The current report describes the case of a 13-year-old girl with an extralobar pulmonary sequestration who presented with chest and back pains without evidence of infection. Her symptoms were discovered to be secondary to torsion and infarction of the pulmonary sequestration. Although pulmonary sequestration is not an uncommon differential diagnosis for chest masses, it is rare for it to present in this manner.

Background: Antegrade enemas have been proven to minimize problems with stool control for many incontinent patients; however, foreign bodies are unsightly, and native tissues have been shown to leak or stricture., Methods: Using a limited laparotomy incision, the appendix or a rolled cecal tube was sutured to the apex of the everted umbilical skin using a V-shaped incision. The skin then was inverted to hide the mucosa. The cecum was plicated around the base of the appendix or cecal tube and then tested by filling the cecum with saline to a pressure of 30 cm H2O., Results: Twenty patients (aged 4.8 to 41 years) with fecal incontinence caused by imperforate anus (17 cases) and other causes underwent this procedure. Two patients had minor strictures that resolved with home dilatations, and one cecal tube necrosed, and the patient has refused reoperation. One patient had minor prolapse and underwent revision. None of the conduits leak. Two patients achieved continence and stopped cannulating their stomas. With adjustment and customization of each enema regimen, stool accidents are infrequent. Follow-up is 22 +/- 14 (mean +/- SD) months., Conclusion: A catheterizeable colocutaneous conduit has been developed that allows for an invisible, leak-proof, and relatively stricture-free means through which antegrade enemas can be given., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: Diaphragmatic pacing can provide chronic ventilatory support for children who suffer from congenital central hypoventilation syndrome (CCHS) or cervical spinal cord injury. The authors report a new thoracoscopic approach for establishing diaphragm pacing., Methods: Between 1997 and 2000, 9 children ranging in age from 5 to 15 years and suffering from these disorders underwent thoracoscopic placement of bilateral phrenic nerve electrodes. A 3- or 4-trocar technique was used to dissect the phrenic nerve in the midchest and suture a phrenic nerve electrode (Avery Laboratories I-110A, Commack, NY) into place. The electrode was tunneled to a subcutaneous pocket in the upper abdomen and attached to an implanted pacing unit., Results: Bilateral electrodes were placed successfully into all patients. The average procedure time was 3.3 hours (range, 2.5 to 4.6), and average hospital stay was 4.2 days (range, 3 to 5). Four patients experienced postoperative complications (pneumonia, atelectasis, bradycardia, and pneumothorax). Average follow-up has been 30 months (range, 15 to 49). Eight patients have reached their long-term pacing goals., Conclusions: Phrenic nerve electrodes can be implanted thoracoscopically and allow the successful use of diaphragmatic pacing therapy. Avoidance of thoracotomy with its associated perioperative morbidity and scarring may encourage wider utilization of diaphragmatic pacing in children., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Purpose: The aim of this study was to characterize the perioperative complications of central venous catheter placement in children infected with human immunodeficiency virus (HIV) METHODS: A retrospective chart review was conducted of all central venous catheters placed by the surgical service into HIV-infected children from 1988 to 1998 at a large urban children's hospital. Complications occurring within 1 month of catheter placement were analyzed for several host and environmental factors., Results: Forty HIV-positive patients underwent 60 central venous access procedures. Thirty-two of the patients were severely immunosuppressed. Eight catheter placements (13%) resulted in perioperative complications, including hemorrhage (n = 2), site infection (n = 2), catheter sepsis (n = 2), thrombotic occlusion (n = 1), and a pleural effusion secondary to catheter malposition (n = 1). Only 3 patients required catheter removal. There was no significant relationship between either hemophilia or thrombocytopenia and perioperative hemorrhage. No significant relationship was found between infectious complications and preoperative white blood cell count, absolute neutrophil count, CD4% and CD4#, suggesting that a patient's compromised immune status should not be considered a contraindication to central venous catheter placement., Conclusion: The complication rate of central venous catheter placement into HIV-infected children is low (<15%), but is still higher than that of the general pediatric population. With careful preoperative preparation this procedure can be performed safely, even in patients with advanced HIV disease. J Pediatr Surg 36:1777-1780., (Copyright 2001 by W.B. Saunders Company.)

Purpose: The aim of this study was to demonstrate the effects of recent technical advances on the safety and benefits of pediatric laparoscopic splenectomy., Methods: A retrospective review was conducted of patients undergoing laparoscopic splenectomy from January 1998 to January 2000. Technical advances utilized during this period included the harmonic scalpel, a specialized flexible hilar retractor, a larger, wire-rimmed specimen bag, and lateral patient positioning., Results: Laparoscopic splenectomy was performed successfully on 18 patients aged 3 to 17 years (median, 9). The indications were hereditary spherocytosis (n = 10), idiopathic thrombocytopenic purpura (n = 5), and other (n = 3). Eight patients had concomitant procedures including cholecystectomy (n = 3), resection of an accessory spleen (n = 3), and other (n = 2). The median operating time, including the concomitant procedures, was 125 minutes (range, 70 to 235). Patients tolerated a regular diet on median postoperative day 1 (range, 1 to 3), and 16 were discharged home on or before postoperative day 2. None of the patients required blood product transfusion or conversion to an open technique. There were no complications, and all patients had returned to usual activity by 2 weeks., Conclusion: With recent technological advances, the laparoscopic approach has become easy to perform, safe, and should be considered the procedure of choice for pediatric splenectomy.

Background/purpose: Before the institution of a standardized feeding regimen (SFR) for hypertrophic pyloric stenosis (HPS) at the authors' institution, the postoperative feeding regimen and, thus, the length of hospitalization for HPS patients was variable. The aim of this study was to evaluate whether a SFR would affect the length of hospitalization or hospital costs for HPS patients., Methods: A 5-year retrospective analysis was performed on 242 patients who underwent pyloromyotomy via a standard right upper quadrant incision. The length of hospitalization and hospital costs were compared in these patients before and after the institution of a standardized postoperative feeding regimen., Results: The SFR decreased total length of hospitalization by 19.4% (3.1 days v2.5 days, P = .002), postoperative length of stay by 21% (1.9 days v 1.5 days, P< .001), total costs by 11.9% (P= .05), direct costs by 7.7% (P= .22), and indirect costs by 18.6% (P= .003). This occurred despite a small increase in costs per day. The SFR did not change the complication rate (5.3% before SFR v6.1% after SFR, P = 1.0)., Conclusion: A postoperative standardized feeding regimen for patients with HPS decreased length of hospitalization and hospital costs without adverse effects.

Background/purpose: When performing an urgent gastrointestinal operation on an immunocompromised child, the pediatric surgeon may have to decide between performing an intestinal anastomosis (and risk leakage or sepsis) or creating an intestinal stoma. This study evaluates the postoperative course of those patients treated with intestinal stomas and the long-term survival rate of such patients., Methods: A 13-year retrospective review of immunocompromised children with intestinal stomas was performed. Patients were assessed as to their diagnosis, indication for surgery, stoma type, postoperative complications (within 30 days of surgery), ostomy-related complications, and survival., Results: 19 stomas (8 ileostomies and 11 colostomies) were created in 18 patients. Six children had immunodeficiency disorders; 12 were immunosuppressed from chemotherapy treatment for cancer. Indications for surgery included infectious complications (n = 8); neoplasm-induced bowel obstruction, perforation, or invasion (n = 10); and Hirschsprung's disease (n = 1). Postoperative complications occurred in 13 cases (68%); two warranted reoperation. Four of six patients with neutropenia had serious postoperative infectious complications. Stoma complications occurred in 6 cases (32%); 1 required revision. All 3 patients in whom bleeding developed from their stoma site were thrombocytopenic. Nine of 18 patients (50%) died, yet no patient died of complications attributable to their stomas. Of the surviving 9 children, 6 underwent stoma takedown at a mean of 19 months after creation; 1 has a permanent colostomy, and 2 currently are undergoing chemotherapy., Conclusion: Although immunocompromised children who require intestinal stomas frequently die of their underlying illnesses and their stomas often produce considerable morbidity, stoma creation does not jeopardize their chance of survival.

Background: Urologic complications after pediatric renal transplantation can adversely effect the outcome and may result in decreased graft survival. Efforts to prevent these complications are worthwhile. This study investigates the incidence of these complications in a clinical transplant program and reports on an animal model used to investigate one possible cause., Methods: In the clinical study, the results of a pediatric renal transplant program at a large children's hospital for a 5(1/2)-year period were reviewed with special attention paid to patients suffering ureteral necrosis. In the experimental study, 9 swine underwent laparotomy, bilateral complete infrahilar ureteric dissection, and extravesical ureteroneocystostomy. On the left side only, the renal and adrenal veins were ligated. The arterial supply remained intact. The right side did not undergo vessel ligation and served as the control. Three pigs each were killed at 3, 8, and 15 days. Kidneys, ureters and a cuff of bladder were examined histologically., Results: In the clinical study 75 renal transplants were performed with a total of 5 cases of early ureteral necrosis. Two of these 5 displayed venous congestion and ischemia, and 2 were associated with kidneys displaying primary nonfunction of the graft. Seventy-one of 75 grafts are continuing to function. One of the 4 early graft losses also had an ischemic ureter. In the experimental study all right kidneys and ureters were normal. All left kidneys had complete hemorrhagic necrosis. Necrosis also was found in 5 of 9 proximal left ureters and in 7 of 9 distal left ureters. Viable left ureters displayed moderate to severe submucosal and periureteric hemorrhage. Four of 9 ureters displayed more damage distally than proximally. The extent of necrosis was similar at 3, 8, and 15 days., Conclusion: In both clinical and experimental studies, venous congestion and subsequent ischemia have been shown to be important causes of ureteral necrosis after renal transplantation.

Background: Hypertrophic pyloric stenosis has been approached using two standard incisions for pyloromyotomy: the circumumbilical (UMB) and the right upper quadrant (RUQ). The UMB approach produces an almost undetectable scar but has been associated with more complications., Study Design: A 5-year retrospective analysis was performed on 344 patients (90 UMB and 254 RUQ) to compare technical and wound complications. The effect of prophylactic antibiotics on wound infection was also evaluated., Results: The intraoperative complication rate was 5.5% (13.3% UMB versus 2.8% RUQ; p = 0.001). The mucosal perforation rate was 3.5% (8.9% UMB versus 1.6% RUQ; p = 0.003). Mucosal perforations increased the mean +/- SD length of hospitalization in UMB patients (3.9 +/- 0.8 versus 2.4 +/- 1.1 days; p < 0.001). The serosal tear rate was 2.0% (4.4% UMB versus 1.2% RUQ; p=0.08). The postoperative complication rate was 5.8% (14.4% UMB versus 2.8% RUQ; p < 0.001), and the wound infection rate was 2.6% (6.7% UMB versus 1.2% RUQ; p = 0.01). Antibiotic prophylaxis decreased the rate of wound infection to 1.8% and eliminated the statistical difference between the groups (4.5% UMB versus 0% RUQ; p=0.16). The rate of other postoperative complications was 3.2% (7.8% UMB versus 1.6% RUQ; p = 0.009). Duration of hospital stay did not differ between the groups overall (2.6+/-1.12 days for UMB versus 2.7+/-1.5 days for RUQ; p = 0.35)., Conclusions: The UMB approach to pyloromyotomy was cosmetically superior but increased complication rates. Technical complications were easily corrected and length of stay was not affected. Wound infections were decreased in both groups by the use of prophylactic antibiotics.

Background/purpose: Spinal dysraphism and neurovesical dysfunction (NVD) frequently are associated in children with anorectal malformations (ARM). This study compares the urodynamic data from a selected group of patients with the results of their spinal and urologic imaging studies., Methods: Twenty-six children (20 with isolated imperforate anus and six with persistent cloacal malformations) were investigated. All patients were evaluated with leak point pressures (LPP), renal ultrasound scan, and voiding cystourethrography. Eight children had urodynamics performed before and after posterior sagittal anorectoplasty (PSARP). The spinal cord was assessed using ultrasonography or magnetic resonance imaging. Current urologic status was obtained to provide long-term follow-up., Results: Twenty-one of 26 children demonstrated elevated LPPs above the established normal value of 40 cm H2O, and 15 of these children had normal spinal imaging study findings. Uroradiographic studies findings showed that 12 of 21 children with elevated LPPs had hydronephrosis or vesicoureteral reflux with seven of these patients having normal spinal cords. LPPs in the eight patients with pre- and postoperative studies were 74 +/- 14.7 cm H2O and 68 +/- 31.8 cm H2O (mean +/- SD), respectively., Conclusions: These urodynamic and radiographic data confirm that NVD (elevated LPP) is common in patients with anorectal malformations despite normal spinal cords. Bladder dysfunction does not appear to be a sequelae of a properly performed PSARP. Patients with ARM and any uroradiographic or clinical urologic abnormality should undergo urodynamic testing even though the spinal studies are normal.

Purpose: To aid in identification of isolated tracheoesophageal fistulas (TEF), many surgeons have recommended the bronchoscopic placement of a ureteric or Fogarty catheter. This method can fail because of intraoperative dislodgment of the catheter. The authors present a new technique that enables us to definitively isolate and treat all H-type fistulas., Methods: Six cases of isolated TEF are presented consisting of 4 H-type fistulas, a proximal pouch fistula, and a recurrent TEF. Three of the patients had undergone a total of four prior failed operations at outside institutions using attempted bronchoscopic catheter placement. On all six patients, bronchoscopy was first performed where the fistula tract was noted in the trachea and a guide wire was passed through the fistula. After orotracheal intubation, the authors performed rigid esophagoscopy; the guide wire was identified and brought out through the mouth. This created a wire loop through the fistula. With the use of x-ray we were then able to visualize the level of the fistula and determine whether a cervical or thoracic approach should be used. Identification of the fistula intraoperatively was then facilitated by traction on the loop by the anesthesiologist., Results: Five of the six TEFs were repaired with neck exploration; one required right thoracotomy. In all patients, the fistula was identified and divided. There were no recurrences or other complications., Conclusion: This new technique is a simple and definitive method in identification and treatment of isolated TEF.

Background: In an effort to avoid infections that can lead to the premature removal of indwelling central venous catheters (CVCs), the surgical technique and host factors present in pediatric recipients of permanent CVCs were reviewed., Study Design: All patients receiving CVCs over a 17-month period were identified. Those patients with fever and positive blood cultures drawn through the CVC within 45 days of line placement were labeled as having early infection. A case-control design was used to select two control patients for each infected patient. Charts from both the infection and control groups were reviewed for several factors present at the time of CVC placement, including fever, neutropenia (absolute neutrophil count [ANC] < 500 and ANC < 1,000), use of perioperative antibiotics, diagnosis, CVC site, and type of CVC. Chi-square test with Yates correction was used to compare the groups. Odds ratios (ORs) and 95% confidence intervals were derived., Results: Among the 473 CVCs placed, early infections developed in 53 patients (12%). The control group consisted of 106 patients. Neutropenia was present in 16 of 53 infected patients versus 8 of 106 controls (p = 0.004, OR = 5.30). Perioperative antibiotics were given to 25 of 53 infected patients versus 72 of 106 controls (p = 0.02, OR = 0.42). Fever was present in 12 of 53 infected patients versus 14 of 106 controls (p = 0.19, OR = 1.92). Factors that were equally prevalent between the groups and that did not appear to influence the CVC infection rate included a diagnosis of malignancy, CVC type, and site of placement. Of the 53 infected catheters, 16 (30%) could not be cleared of infection and were removed., Conclusions: This study documents that neutropenia and failure to administer prophylactic antibiotics are risk factors for the development of early CVC infection in pediatric patients. To avoid early infection and possible premature CVC removal, we recommend that placement of permanent CVCs be postponed until the ANC is > 1,000. Perioperative antibiotics should be given. A trend toward higher infection rates was seen in patients with preoperative fever.

The optimal surgical care of patients with imperforate anus begins with appropriate decision making in the critical newborn period. In most cases the decision to create a colostomy should be delayed until the infant is 18 to 24 hours old. Except in cases of a rectoperineal fistula, most neonates are best treated with a completely divided left-lower-quadrant colostomy between the descending and sigmoid colons. Female patients with cloacal anomalies must be recognized at birth so that all urgent urologic evaluations can be performed. Hydrocolpos and obstructive uropathy are common in these neonates and warrant urgent decompression of the urinary tract with a vaginostomy and/or vesicostomy as well as a colostomy. Renal ultrasonography and voiding cystourethrography are mandatory for all patients regardless of the height of the defect. It is critical to discover the important precursors to renal insufficiency including renal agenesis, renal dysplasia, and vesicoureteral reflux in the neonate. The presence of these anomalies mandates early consultation with a pediatric urologist because the morbidity and mortality of these lesions often exceed those of the imperforate anus. Spinal cord anomalies are common and can be found even in patients who have normal plain films and low defects. Spinal ultrasonography or magnetic resonance imaging should be performed in all neonates to rule out occult spinal pathology such as tethered cord or lipoma of the cord. Efficacious and cost-effective care of patients with imperforate anus begins with a carefully thought out plan in the neonate. Optimal execution of the evaluation and surgical treatment at this phase sets the stage for the best possible outcome later in life.

Unilateral testicular trauma in the postpubertal male can lead to alterations in semen analysis, but it is not clear what effect this has on fertility. To better understand how surgical treatment of testicular trauma affects both fertility and testicular histology the following study was performed. Eighty postpubertal Lewis rats were divided into eight equal groups with one group serving as a control. In the 70 remaining rats the left testicle was subjected to blunt or penetrating injury. The testicles were either left untreated, were removed, or were repaired with sutures or mesh before being returned to the scrotum. Following recovery, each male was allowed to mate to determine fertility. Fertility rates were significantly lower in all postinjury groups except the postinjury orchiectomy group. Histological analyses showed nonspecific inflammation, smaller tubules, and impaired spermatogenesis in all postinjury testicles regardless of the type of treatment. Contralateral testicles had no evidence of autoimmune injury and were essentially identical to the control group. In the postpubertal Lewis rat, unilateral testicular trauma leads to impaired fertility unless the injured testicle is removed soon after the injury. Various methods of repairing the injury did not improve fertility. In spite of the impaired fertility, the contralateral testicle appears histologically normal.

Choledocholithiasis in neonates and infants has been reported only rarely. Infants with complications of prematurity are more predisposed to development of biliary calculi. With the current widespread use of diagnostic ultrasonography, more neonates may be found to have gallstones and common bile duct stones. We describe a case of choledocholithiasis and cholelithiasis in a premature neonate successfully treated by surgical placement of a cholecystotomy tube and irrigation of the biliary system.

As an alternative to bladder mucosa, free grafts of tubularized peritoneum were used as urethral substitutes in a rabbit model of hypospadias. In group 1, six mature rabbits underwent partial penile urethrectomy followed by interposition of a 2-cm-long peritoneal-lined tube graft. These animals had urethrograms performed at 3 months and were killed at 6 (n = 4) or 12 (n = 2) months. In group 2, six rabbits underwent total penile urethrectomy with placement of 3-cm-long grafts. These animals were killed 1 to 4 weeks after surgery. Clinical assessment and gross examination of the 12 rabbits showed no urinary retention, two small fistulas at the proximal anastomosis, and no strictures or diverticular. At 6 and 12 months (group 1) the urethra had healed completely and the graft edges were not visible. In group 2, 1 to 4 weeks after surgery the graft was intact and the interface between the graft and native urethra was visible. Histological studies of the grafts were compared with control peritoneum. At 1 week, a high-density single-cell layer was present. Beginning at 2 weeks, a multilayered epithelium was present, which became more organized in the older grafts. Neovascularity became visible in the subepithelial layer at 2 weeks. Acute inflammatory cells were present early and were replaced by a palisading layer of lymphocytes and plasma cells in the older grafts. Minimal fibrosis was observed. Tubularized peritoneal free grafts are a promising new urethral substitute. Graft placement is technically simple. Replacement of the peritoneum by a multilayered epithelium resembling transitional epithelium occurs early after graft placement. As much as 1 year later, minimal scarring is present.

Osteomyelitis of the spine is a well-recognized delayed manifestation of septicemia but has not been recognized as a complication of total parenteral nutrition. We report five cases of spinal osteomyelitis that were clinically recognized 1 to 13 months after total parenteral nutrition catheter-induced septicemia. Radiographic evidence of osteomyelitis was seen in all five patients. In three patients, culture of bony aspirates was positive for the same organism as from the blood. In one case, the diagnosis was established by histology, and in one the diagnosis was based on radiographic and radionuclide evidence of osteomyelitis. The organism responsible was Staphylococcus aureus in two cases, Candida albicans in another two cases and C tropicalis in one case. The septic episode that preceded osteomyelitis was treated with systemic antibiotics and catheter removal in four patients, and antibiotics without catheter removal in one patient. Nevertheless, osteomyelitis occurred, requiring bracing or operative debridement as well as prolonged antibiotic therapy. Spinal osteomyelitis may occur as a delayed manifestation of total parenteral nutrition catheter-induced septicemia. Prompt and effective treatment of septicemia is indicated but may not always be sufficient. Clinical suspicion is the key to the correct and early diagnosis of osteomyelitis and therefore to adequate treatment.

Early pyeloplasty for the treatment of congenital ureteropelvic junction obstruction to maximize nephron salvage is only justified if the potential hazards of operating on small infants are avoided. The records of all infants who underwent pyeloplasty by the authors over a 7-year period were analyzed. The outcome of surgery in the younger infant group (YIG; patients less than 2 months of age) was compared with that of the older infant group (OIG; patients more than 2 months of age). Preoperative evaluation in cases of mild or moderate hydronephrosis was directed toward ruling out a nonobstructed collecting system and included voiding cysto-urethrography and serial ultrasonography and/or dual isotope diuretic renography. Open pyeloplasty was performed if collecting systems had deteriorated or were demonstrated to be obstructed; it was also performed for severe cases of hydronephrosis. Postoperative assessment consisted of serial ultrasonography and/or nuclear imaging to confirm decompression and relief of obstruction. Thirty three pyeloplasties were performed in 31 patients in the YIG (two bilateral), and 33 were performed in 32 infants in the OIG (one bilateral). The only significant differences between the groups were as follows. Patients in the YIG were more likely to present in utero (87% v 53%; P < .01), whereas those in the OIG were more likely to present with a urinary tract infection (44% v 0%; P < .01). The YIG was more likely to have nephrostomy drainage postoperatively (67% v 45%; P < .01). In the overall series, there were five complications, all of which were postoperative infections requiring intravenous antibiotic therapy. Two occurred in the YIG and three in the OIG.(ABSTRACT TRUNCATED AT 250 WORDS)

The National Wilms' Tumor Study 3 (NWTS-3) recommended treatment of bilateral Wilms' tumor with initial biopsy followed by chemotherapy with subsequent operation to resect the remaining tumor. This study was performed to determine if this approach preserves renal mass and function when compared with initial surgical resection followed by chemotherapy. Over a 20-year period (1970 to 1990), 15 patients with synchronous bilateral Wilms' tumor were treated at the Childrens Hospital of Los Angeles. Eight patients in the surgical group underwent initial unilateral nephrectomy with contralateral biopsy, wedge resection, or partial nephrectomy and subsequent chemotherapy. The seven patients in the chemotherapy group underwent bilateral tumor biopsy, followed by chemotherapy and subsequent tumor resection. Patients were assigned to each group in a nonrandomized manner according to the preference of the attending oncologist and surgeon. Comparison of the two groups showed no significant differences in sex distribution, initial renal function, tumor histology, dose and field of radiotherapy, presence or absence of positive surgical margins, and local recurrence rates. Patients in the surgery group were slightly older than those in the chemotherapy group: 3.6 +/- 2.2 versus 2.3 +/- 2.2 years. The percent of renal mass involved by tumor for the surgery group was 52 +/- 12 versus 73 +/- 16 for the chemotherapy group (P = .03). The percent of renal mass preserved following all operations, local recurrence rates, incidence of metastases, and survival was nearly identical between the two groups. There were three cases of renal failure in the surgery group and one case of renal failure in the chemotherapy group.(ABSTRACT TRUNCATED AT 250 WORDS)

We evaluated the effect of total parenteral nutrition (TPN) on abnormalities of hepatic histology. Liver biopsies of 93 patients who were concurrently receiving TPN were compared with a control group of 35 patients. The control patients were matched for extent of preexisting liver disease and degree of illness. The liver biopsy specimens were blindly graded on 19 histopathologic findings, including fatty change, portal inflammation, and cholestasis. Twenty-seven clinical variables, such as preexisting liver disease, the presence or absence of sepsis or shock, and number of days receiving TPN before biopsy, were recorded. Individual and partial correlations were established between the clinical variables and histopathologic findings. The control and TPN groups proved to have been closely matched regarding the extent of risk factors for hepatic histopathologic features. Positive correlations were repeatedly found between abnormal hepatic histologic features and preexisting liver disease, abdominal sepsis, renal failure, and blood transfusion but not with the administration of TPN. We conclude that clinical phenomena, such as existing liver disease, renal failure, and abdominal sepsis, rather than administration of TPN, had a predominant effect on histopathologic features in this group of patients.

Gastrostomy and staged repair are techniques frequently recommended for the management of esophageal atresia with distal tracheoesophageal fistula (EA-TEF), especially for those infants at high risk. We describe 42 consecutive patients with EA-TEF treated during the past 8 years. Staged repair and preliminary gastrostomy were not routinely employed. Fifteen infants were considered to be at high risk (Waterston class C). Surgical treatment via an extrapleural approach consisted of fistula division and primary single-layer end-to-end esophageal anastomosis. Four patients required proximal esophageal circular myotomy. Four patients early in the series received a gastrostomy at or before definitive repair for various life-threatening indications. One patient had fistula division only and died before esophageal anastomosis was possible. Two neonates died before repair and another died after repair. The deaths in this series of patients were unrelated to EA-TEF. One patient developed a clinically significant anastomotic leak. Four patients required multiple dilatations for anastomotic stricture. Fundoplication was necessary in 3 patients with symptomatic gastroesophageal reflux. Our data demonstrate that excellent overall survival (90%) with low morbidity (15%) can be achieved using primary repair without preliminary gastrostomy in most neonates with EA-TEF. We believe that mortality in high-risk patients with EA-TEF is due to associated life-threatening anomalies.

Human gallstones were surgically implanted in the gallbladders of six pigs. Through cholecystostomy catheters, methyl tertiary-butyl ether (MTBE) was infused from 3 to 5 days. MTBE successfully dissolved 19 of the 20 cholesterol stones and partially dissolved one mixed cholesterol-bilirubin stone. Gross and microscopic examination of abdominal organs revealed mild superficial ulcerations of the gallbladder and mild to moderate chronic inflammatory changes in the gallbladder of animals treated with MTBE infusion. There were no other significant changes within other abdominal organs except for mild inflammation of the duodenum in one animal and of the common bile duct in another. Because of its efficacy and limited deleterious effects, MTBE may be a good solvent when dissolving pure cholesterol gallstones in the gallbladder.