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BACKGROUND/PURPOSE: Routine contralateral exploration in infants and children with unilateral clinical inguinal hernia is performed by many surgeons in a selected population of patients based on a presumed high incidence of patent processus vaginalis. Our purpose is to report the actual incidence of contralateral manifestations in infants and children after the repair of unilateral inguinal hernia. METHODS: From July 1985 through December 1995, 1,052 infants and children with unilateral inguinal hernia or hydrocele were treated in our hospital without contralateral exploration. Among them, 1,001 patients (95.2%) were followed up for 1 to 11 years to determine if contralateral hernia developed after unilateral inguinal herniorrhaphy. RESULTS: The overall incidence of contralateral hernia was 11.6% (116 of 1,001). In boys, the incidence was 13.1%, 13.7%, and 11.7% in those under 1 year, under 2 years of age, and in total, respectively. In girls, the incidence was 9.6%, 13.9%, 11.3%, in those under 1 year, under 5 years of age, and in total, respectively. The side of the initial repair did not influence the subsequent development of contralateral inguinal hernia. In children with hydrocele, the incidence of contralateral hernias was lower (7.6%). In girls with sliding hernias the contralateral occurrence was 12.5%. CONCLUSION: Given this low incidence of contralateral hernia after unilateral inguinal herniorrhaphy, the authors do not recommend contralateral exploration for infants and children with unilateral inguinal hernia.

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Homologous blood transfusions have associated infectious and immunological risks. Since 1989 the authors have conducted predeposited autologous blood transfusions (PABT) for infants and children in whom transfusions were expected to be required during an elective operation. Autologous blood was deposited in 13 patients ranging in age from 9 months to 10 years (median, 21 months) with weight from 7.3 kg to 33.6 kg (median, 10.5 kg). They included eight patients with Hirschsprung's disease, three patients with benign tumors, and two others. The volume of predeposition was calculated to maintain the patients' hematocrit at 30% after collection. Blood was deposited once or twice, 1 to 2 weeks before the operation. The actual volume of predeposited blood was 19.1 +/- 2.4 mL/kg in infants with Hirschsprung's disease, 21.8 +/- 10.0 mL/kg in children with Hirschsprung's disease, and 12.6 +/- 2.2 mL/kg in children with other diseases. Nine patients were operated on using only PABT, 2 patients required homologous blood transfusions in addition to PABT, and 2 patients did not require any blood transfusions. No complications occurred as a result of PABT except preoperative anemia. PABT is a safe and effective means of procuring blood for intraoperative transfusions in infants and children undergoing major elective general pediatric surgical procedures.

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Repair of esophageal atresia is usually performed by a thoracic approach. In cases associated with a tracheoesophageal fistula (TEF) located in a high position, however, the cervical approach is a reasonable alternative. In the literature, the authors found only three patients repaired by this approach. This report describes three additional cases of esophageal atresia successfully repaired by the cervical approach. Three neonates with esophageal atresia and TEF were confirmed as having an unusually high position of the distal TEF by the preoperative bronchoscopy and contrast study. The transcervical approach for repair was chosen. The skin was incised transversely at the right supraclavicular region, and the sternocleidomastoid muscle and the carotid sheath were retracted posterolaterally. After the division of the TEF, the suture site of the tracheal fistula was covered by a flap of the sternothyroid muscle that was inserted between the trachea and the esophagus, thus avoiding opposing suture lines. These cases emphasize that pediatric surgeons should be aware of the presence of cervical esophageal atresia in which distal TEF is located above the clavicle, and suggest that cervical repair is feasible for the patient whose distal TEF moves up above the first rib on inspiration. The most reliable methods for detecting the location of the distal TEF are telescopic bronchoscopy and contrast study.

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An adolescent girl with congenital bronchopulmonary-foregut malformation (BPFM) is reported. The patient had a hypoplastic, non-functioning right lung with the main bronchus originating from the oesophagus. The pulmonary artery of the "oesophageal lung" was supplied by systemic circulation from the descending aorta, and the venous flow drained through a hypoplastic right pulmonary artery (RPA) into the large left pulmonary artery (LPA). This case was a rare type of left-to-right shunt and demonstrates that oesophagography, pulmonary angiography and aortography are important in demonstrating the haemodynamics involving this malformation.

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Idiopathic gastric volvulus is not rare, especially in the neonate and in infancy. Between 1966 and 1980 we managed 44 cases of gastric volvulus. In 22 of the cases, initial examination was performed under 1 year of age. The main symptoms in this group were vomiting and abdominal distention, while those in the group over 2 years of age were abdominal distention, weight loss, nausea, appetite loss etc. The upper G.I. series were the most important in diagnosis. There was only one case of acute volvulus, which was treated operatively on an emergency basis. Chronic volvulus could be treated conservatively, except in 2 cases. This consisted in the positioning of the patient in the upright right recumbent position after feeding, for at least 1 hour. In the supine position, the gastric fundus is filled and dilated when the milk is poured into the stomach, the fundus is pulled postero-caudally and the antrum is pulled upwards, resulting in the combined type of organo-axial and mesenterico-axial volvulus. Over 2 years of age, 77% required operation. The fixation of the gastric fornix with the diaphragm was performed, using 5 or 6 stitches. The result was quite satisfactory. We recommend this procedure in this operation.

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