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BACKGROUND/PURPOSE: Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The authors have attempted to determine the age- and gender-stratified incidence of contralateral hernia and the necessity of routine bilateral procedures. METHODS: This is a prospective study of 656 patients during a 34-month period at a single institution. Patients with unilateral hernia underwent an ipsilateral procedure only, regardless of age, gestational age, or gender. Follow-up was 6 to 40 months (mean, 25.5 months). Chi-square analysis was used for intergroup comparison (P < .05 significant). RESULTS: Of 656 children, 108 (16.5%) presented with synchronous bilateral hernias. Bilateral inguinal hernia was significantly more common in premature infants (28.0%) and young children (33.8% if <6 months, 27.4% if <2 years). Of the remaining 548, a metachronous contralateral hernia developed in 48 (8.8%) at a median interval of 6 months (range, 4 days to 7 years). This incidence was 13 of 105 (12.4%) in infants less than 6 months of age, 20 of 189 (10.6%) in children less than 2 years of age, 8 of 54 (14.8%) in premature infants, 6 of 81 (7.4%) in girls, and 8 of 29 (27.6%) in children with an incarcerated hernia. In the latter group, P < .05, chi2 analysis. CONCLUSION: Routine contralateral inguinal exploration, without clinical evidence of a hernia, may be advisable in children with incarceration and possibly in premature infants. The low incidence of contralateral hernias in all other patients, regardless of gender or age, does not justify routine contralateral exploration.

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Metabolic abnormalities described in pyloric stenosis are now rare, probably because of prompter recognition of the disease. This report reviews the trend in presentation over three decades. All infants treated for pyloric stenosis during three mid-decade target periods were reviewed. Comparison between the 1975 group and the 1985 group and between the 1995 group and previous decades were designed to identify the impact of ultrasonography, since this modality has only been available in the last decade. Parameters included age at diagnosis and incidence of water and electrolyte imbalance as measures of delay in presentation. Two hundred eighty-three patients were reviewed. Mean age (weeks) at presentation was 5.4+/-3.0 in 1975, 4.6+/-2.0 in 1985, and 3.4+/-1.3 in 1995 (P < .05, ANOVA). Overall, 88% had no electrolyte anomalies on admission. There was no statistical difference in frequency of abnormal results between the three decades. Total and postoperative hospitalization was significantly shorter in the recent period: in 1985, 5.34 and 4.36 days; in 1985, 4.48 and 3.4 days; and in 1995, 3.8 and 2.8 days. These data show that pyloric stenosis is now recognized earlier than in previous decades. The availability of ultrasonography cannot solely be credited for earlier diagnosis, since this trend was already apparent before its introduction. The "classic" metabolic derangements associated with pyloric stenosis have been highly uncommon for the past three decades.

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Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon. Several strategies for lengthening of the proximal esophageal segment have been used with relative success. Autogenous tissue conduits have resulted in less than optimal long-term results. Five patients since 1991 with long gap esophageal atresia (2 with distal tracheo-esophageal fistula [Type C], and 3 with isolated esophageal atresia [Type A]) underwent mobilization of the distal esophagus to the level of the diaphragm in order to perform a primary anastomosis. A retrospective analysis evaluated the timing of repair, when oral feeds were successfully begun, with particular attention to any ischemic sequelae related to the distal esophageal dissection. Two patients underwent immediate repair, three had delayed repair. There were no anastomotic leaks. Three patients healed without stricture. Of four patients who survived long-term, three patients are eating well and only one still requires jejunoenteric supplementation. Classic teaching dictates that dissection of the distal esophagus should not be done because of disruption of its segmental blood supply. In this series, distal esophageal mobilization was successful in facilitating a primary anastomosis. These results are encouraging as an alternative to the high morbidity and marginal long-term results of interposition grafting or gastric transposition.

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BACKGROUND: Advances in neonatal intensive care have improved the survival of the extremely premature infant. However, survival at less than 25 weeks' gestational age remains tenuous, with intestinal perforation presenting a significant mortality. METHODS: During an 18-month period from 1995 to 1996, nine patients weighing less than 750 g (range, 485 to 740 g; mean, 615 g) presented with intestinal perforation. All patients were treated with peritoneal drainage. Drains were removed after clinical improvement and the cessation of peritoneal drainage. RESULTS: Seven patients survived the initial drainage procedure (78%). At a mean follow-up of 12 months, the six long-term survivors are all tolerating full enteral feeds, and none developed intestinal strictures or intraabdominal abscess. No patient required subsequent celiotomy. Peritoneal drainage has previously been considered in some centers as temporary therapy in extremely ill neonates deemed unlikely to survive operation. The authors have adopted drainage as the sole treatment in selected patients. CONCLUSION: Peritoneal drainage alone may be considered definitive therapy for intestinal perforation in the majority of micropremature infants.

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Although the pathogenesis of necrotizing enterocolitis remains uncertain, ischemia appears to be an important contributing factor to the development of this disorder. Reperfusion plays a major role in ischemia-related injury, and oxygen free radicals produced during reperfusion most likely contribute to the injury. These oxidants can be generated during prostanoid metabolism, which increases during reperfusion of ischemic gut in adult subjects. The present study was designed to: 1) examine the effects of superior mesenteric artery occlusion, e.g. ischemia and reperfusion in vivo on the development of histopathologic intestinal injury; 2) determine whether products of arachidonic acid metabolism, e.g. prostanoids are increased during reperfusion of ischemic gut; and 3) determine whether oxygen free radical scavengers attenuate the injury in newborn pigs. Chronically catheterized placebo-pretreated newborn pigs exposed to ischemia-reperfusion, placebo-pretreated nonischemic control pigs, and polyethylene glycol-superoxide dismutase (SOD) plus polyethylene glycol-catalase (CAT)-pretreated, ischemic pigs were studied by examining changes in intestinal circulation, oxygenation, prostanoids, and tissue injury. In the placebo-pretreated pigs, intestinal blood flow decreased to very low levels during superior mesenteric artery occlusion. During reperfusion, blood flow increased, but remained below baseline. After ischemia, oxygen uptake returned to values that were similar to baseline. Intestinal efflux of the vasodilator 6-keto-prostaglandin F1alpha was evident (p < 0.05 versus no or zero efflux) during early reperfusion. Histopathologic scoring of terminal ileal samples showed significant mucosal necrosis, surface epithelial disruption, lamina propria congestion and hemorrhage, submucosal hemorrhage, edema, and increases in cells compared with the placebo-pretreated nonischemic pigs. In the SOD plus CAT-pretreated ischemic pigs, changes in intestinal blood flow, oxygen uptake, 6-keto-prostaglandin F1alpha efflux, and the pattern of the ileal tissue injury did not differ significantly from the placebo-pretreated ischemic pigs. In summary, superior mesenteric artery occlusion for 1 h and reperfusion for 2 h resulted in severe intestinal ischemia, early postocclusive limited increases in intestinal perfusion and oxygen uptake, efflux of vasodilating prostanoids during early reperfusion, and signs of ischemic tissue injury in the placebo- and SOD plus CAT-pretreated pigs. This study demonstrates that, after superior mesenteric artery occlusion and reperfusion, severe intestinal tissue injury is detected in vivo, prostanoid efflux increases, and SOD plus CAT given just before occlusion does not attenuate the extent of injury in newborn pigs.

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PURPOSE: Feeding tube access with an antireflux procedure is frequently necessary in children with severe neurological deficits. Fundoplication in this particular group of patients has many complications and a reported failure rate of 40% to 50%. Recently, the use of a feeding Roux-en-Y jejunostomy has been advocated in this population. METHODS: Since December 1993, over a 6-month period, the authors performed 12 Roux-en-Y jejunostomies. All children had documented gastroesophageal reflux. One patient had a prior failed Nissen fundoplication, and none of these patients were feeding significantly by mouth. Postoperative follow-up has been 12 months. RESULTS: There were no deaths in this series. One patient required early revision of the stoma because of marked prolapse. One 11-month-old infant required reoperation 7 days postoperatively because of tube dislodgment. Eight of the 12 patients required out-patient procedures to unplug or replace the jejunostomy tube. CONCLUSION: The operation may be beneficial in a subset of neurologically impaired children who will never be able to ingest significant calories by mouth. It may also be useful after a failed fundoplication. The main postoperative complications were plugging and dislodgment of the jejunostomy tube, which if they occurred early, required x-ray confirmation for catheter placement.

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Chylothorax is an uncommon condition that may be associated with significant morbidity and mortality. The authors report a case of traumatic chylothorax attributed to child abuse and describe our management with tube thoracostomy and nutritional support with medium-chain triglycerides. Child abuse should be suspected in any case of chylothorax when no other etiology is evident and particularly when other signs of abuse are present.

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We report a family in which three members have thoracolaryngopelvic dysplasia (Barnes' syndrome). This family illustrates the phenotypic variability seen in this rare clinical entity and highlights the medical and surgical management necessary in such cases.

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The authors describe a noninvasive technique for the management of giant omphaloceles. Two patients with giant omphaloceles were managed with external compression. Dry sterile dressings were used, buttressed by an Ace bandage in the first case and by a handcrafted Velcro abdominal binder in the second. The binder was tightened every 2 or 3 days. Renal, cardiovascular, respiratory, and gastrointestinal parameters were measured regularly to determine whether the binder was too tight. The first patient had only occasional emesis, and the defect was repaired after 40 days of compression. The second patient experienced intermittent hypertension, occasional emesis, and mild oxygen desaturation, which resolved when the binder was loosened slightly. The fascia muscle and skin were closed after 30 days of external compression. Both patients are currently living at home and doing well. This form of external compression is an effective, inexpensive, and low-risk method for the gradual reduction of giant omphaloceles, and should be considered for patients born with this problem.

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Hypertrophic pyloric stenosis can be diagnosed accurately by physical examination alone. However, ultrasonographic confirmation is obtained in the majority of cases, often before clinical evaluation by the surgeon. The present study examines whether the easy access to ultrasonography by the primary physician has affected the care of infants with pyloric stenosis. During a 24-month period, 100 infants were treated for pyloric stenosis at the authors' institution. There were 78 boys and 22 girls; the age range was 9 to 90 days (median, 30.0 days). The children were referred for surgical evaluation, but abdominal ultrasonography was ordered concomitantly (or within 1 hour of surgical consultation) in all cases. The median age at the onset of the first symptoms was 24.0 days. The time between onset and hospital admission was less than 7 days for 72 patients, and more than 2 weeks for seven. Metabolic alkalosis or acidosis, hypokalemia, hypochloremia, and dehydration were noted in 10%, 5%, 3% and 9%, respectively. Six infants had prolonged pre- and postoperative courses, because of prematurity (4) or associated conditions (2). For the remaining patients, total hospitalization period and postoperative stay were 3.8 +/- 0.9 days and 2.8 +/- 0.6 days, respectively. Although the diminished importance of clinical skills in the diagnosis of pyloric stenosis may be regrettable, the availability to the primary care physician of this easy, safe, inexpensive, and reliable imaging modality may contribute to prompter treatment. The patients were hospitalized, with a correct diagnosis, within days of the appearance of the initial symptoms. Because so little time had elapsed, water and electrolyte imbalances were not present, and the patients could be operated on within hours of admission.

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BACKGROUND: Unlike familial polyposis coli, where the premalignant nature of adenomatous polyps is well established, the cancer risk in juvenile polyposis has generally been considered not increased. METHODS: This study reviews all cases of juvenile polyposis reported in the English language to date to assess the occurrence and prognosis of carcinoma in the gastrointestinal tract. RESULTS: A total of 218 patients met the inclusion criteria. Mean age at diagnosis was 18.5 years (range: 9 months to 67 years). No gender preference was identified. The most common presenting symptom was chronic anemia, followed by acute gastrointestinal bleeding, rectal prolapse of polyp, protein-losing enteropathy, and intussusception. A family history of juvenile polyposis could be established in approximately 50% of patients, and associated congenital malformations were detected in 15%. Ninety-nine patients underwent 138 gastrointestinal operations: 121 colorectal, 12 gastric, and 5 small intestinal procedures. The development of a gastrointestinal carcinoma was reported in 36 cases (17%). Mean age at diagnosis of carcinoma was 35.5 years (range: 4-60 years). Most malignancies were located in the distal colon and rectum, with only one case of gastric and one case of duodenal carcinoma. Tumor stage at diagnosis was usually advanced, with poor survival figures. CONCLUSIONS: This study shows that juvenile polyposis syndromes carry a more significant risk of carcinoma than generally appreciated. Therefore, more intense endoscopic surveillance may be warranted, and definitive surgical options should often be considered in these syndromes.

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A 9-year-old girl presented with anemia, fever, and poor growth over a 2 1/2-year period. On physical examination, a right lower quadrant mass was palpated. Her signs and symptoms were consistent with Castleman's disease of the plasma cell type. The mass, a giant hyperplastic lymph node, was excised, and the patient's symptoms resolved. Castleman's disease is a benign lymph node disorder that occurs very rarely in the pediatric population and is cured by operative excision of the lymphatic mass.

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OBJECTIVE: To determine whether nonoperative management of splenic and hepatic injury in the multiply injured pediatric and adolescent patient is both safe and efficacious. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS: All patients younger than 19 years old who suffered trauma to the spleen or liver between February 1978 and December 1991 (n = 103) were retrospectively identified by a trauma registry. These patients were divided into three groups: the group as a whole, those suffering multiple injuries, and those suffering either head injury or injury remote from the abdomen that required operative repair. MAIN OUTCOME MEASURES: Injury severity and outcome within each group of patients were compared based on whether the splenic or hepatic injury was managed operatively or nonoperatively. RESULTS: Mean Injury Severity Scores among the multiply injured patients were not different depending on whether the splenic or hepatic injury was managed nonoperatively or operatively. Except for a higher incidence of transfusion requirement among patients who were treated operatively, measures of morbidity among the multiply injured patients did not differ based on treatment. The success rates of nonoperative treatment among all patients, those with multiple injuries, and those with either head injury or remote injury that required surgery were 94%, 90%, and 86%, respectively. CONCLUSION: Nonoperative management of splenic and hepatic injury in multiply injured pediatric and adolescent patients, including those with head injury and injury remote from the abdomen that requires surgical intervention, is successful and is not associated with a prohibitive morbidity.

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This study was undertaken to identify the pathologic processes in premature infants weighing less than 1000 gm who require surgery, and the outcome of such operations. These neonates required surgery for NEC and PDA. Congenital anomalies were not encountered in our series. No increased mortality due to surgery was observed, and overall mortality was comparable for infants less than 1000 gm and for premature infants with similar diseases. We conclude that surgery in premature infants less than 1000 gm is performed for acquired diseases, and mortality is not increased by the need for surgery.

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A teenager with massive rectal bleeding had a positive 99mTc-pertechnetate abdominal scan. At laparotomy, an arteriovenous malformation of the jejunum was found. There was no evidence of a Meckel's diverticulum. The persistent problem of the positive technetium scan warrants increased utilization of preoperative visceral angiography.

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Over 10 years, 8 infants required surgery for central diaphragmatic herniation. Contrast peritoneography and technetium-99m-sulfur colloid radionuclide scanning were the most definitive diagnostic aids. Associated anomalies included variations of the pentalogy of Cantrell. A midline gastroduodenal loop was found in two infants. Six infants are alive and well 6 months to 3 years postoperatively. An abdominal approach is preferred if there is an intestinal hernia, associated gastrointestinal anomalies, or if a bilateral defect is present.

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For the past 14 years, a simplified operation utilizing a metal strut for internal fixation has been used to repair pectus anomalies in 123 children. Subperichondrial cartilage resection is preformed through small incisions in the pectoral muscles. No sternal osteotomy required. A malleable strut is passed transsternally and removed in four to six months, frequently under local anesthesia. All children who underwent this procedure were discharged within five to six days, and no transfusions were necessary. The use of the technique has shortened operative time and decreased the necessity for extensive postoperative pulmonary physiotherapy. In 75 children followed for over 5 years, cosmetic results have been excellent, and self-image has improved substantially. In only 1 child was there a recurrence impressive enough to warrant reoperation.

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Three children--ages 4 months, 5 months, and 14 years--have been on a program of total parenteral nutrition at home for ten, 23 and 44 months respectively, as of January, 1978. Using a specially designed silicone rubber catheter, placed in the right atrium, total nutritional needs of these children were delivered nightly by family members; the children carried out normal activity during the day with the catheter line maintained by a heparin lock. Normal skeletal development and weight gain have been achieved while allowing these children normal social and psychlogic development outside the hospital. During the course of the therapy the patients had multiple metabolic abnormalities which were successfully treated by replacement therapy. The duration of catheter patency ranged from three to 22 months. Catheter sepsis or mechanical failure occasionally required catheter removal and replacement.

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