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A study of 406 consecutive children operated upon for appendicitis from July 1982 to July 1987 was compared with a previously published study of 657 children with the same diagnosis operated upon between 1972 and 1982. This was done to determine if the methods of therapy continue to yield low complication rates and zero mortality rates. The routine use of antibiotic coverage for both aerobic and anaerobic bacteria in perforated appendicitis resulted in low complication rates, 3.2 per cent for major and 2.5 per cent for minor complications. Major complications included small intestinal obstruction and intra-abdominal abscess. Minor complications included wound infection and prolonged ileus. These rates are similar to those of the first investigation. The mortality rate continued to be zero. Complete peritoneal lavage was used in patients with generalized peritonitis or extensive localized peritonitis. Operative lysis of adhesions for small intestinal obstruction was required in four of these patients. This did not occur in patients with perforated appendicitis with abscess formation or more localized peritonitis who had no lavage. The technique rather than the disease process may be responsible for the complication.

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There are various means to control bleeding gastroesophageal varices in children: sclerotherapy by injection, esophageal transection and variceal ligation, and different portosystemic shunts. Because of a high incidence of shunt thrombosis in children, many clinicians prefer other forms of therapy. However, only a successful shunt will lower the elevated portal venous pressure and eliminate the varices. This report describes a type of portosystemic shunt that will remain patent, even in an infant.

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Fifty-four neonates with necrotizing enterocolitis (NEC) were separated on basis of outcome. Of 35 factors compared between a high-risk and a low-risk group, only six were found to be statistically significant and useful in the development of a NEC score: number of days before beginning enteral feedings; blood pH; serum bicarbonate concentration; white blood cell differential; abdominal tenderness; and presence of portal vein gas. All laboratory values and physical and radiographic findings were from the initial presentation of NEC. Neonates with a score of 3 or more are at an increased risk of developing severe NEC with a greater than 50% mortality. The study suggests that enteral feedings should be withheld from neonates at risk of developing NEC for the first 12 days of life.

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Six hundred and fifty-one patients with appendicitis were reviewed and an over-all perforation rate of 36.5 per cent accompanied by a major complication rate of only 3.38 per cent and an over-all complication rate of 9.06 per cent was reported. This low complication rate despite a high level of perforation can be attributed to the use of antibiotic regimens effective against both aerobic and anaerobic organisms. A thorough irrigation and flushing of debris and exudate from the abdominal cavity of patients with ruptured appendicitis may improve these rates.

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Radiation injury to the kidney, first reported almost eighty years ago, may vary from subclinical changes in renal blood flow or enzyme activity to clinically significant hypertension and/or renal failure. A child with radiation-induced hyperreninemic hypertension was cured by nephrectomy. The microscopic, subclinical, and clinical changes of irradiation injury are reviewed. The etiology of radiation-induced hypertension, methods of radioprotection, and early detection of radiation renal damage are discussed.

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The results of this study demonstrate that there is abnormal esophageal function in patients who have undergone repair of esophageal atresia. The diagnostic tests used may be too sensitive as the abnormalities demonstrated have little clinical relevance. In addition, there was an inverse relationship between signs and symptoms of esophageal dysfunction and the age of the child. The abnormalities are probably intrinsic and only secondarily affected by surgical treatment. Increased tension at the gastroesophageal junction is a likely factor in the production of gastroesophageal reflux. Esophageal dysfunction does not necessarily lead to detrimental gastroesophageal reflux with the sequela of repeated respiratory infections, failure to gain weight or esophageal stricture. Only patients who have such signs or symptoms need to undergo evaluation of esophageal function to determine if there is an abnormality. The results of the studies then document the need for an antireflux procedure.

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Postoperative intussusception is a documented complication of pediatric surgical and pediatric urologic abdominal operations. In contrast to "primary" intussusception's triad of crampy abdominal pain, palpable abdominal mass, and "currant jelly" stools, postoperative intussusception is generally characterized by abdominal pain and vomiting. An abdominal mass is not usually palpable, and few children have bloody stools. Proper diagnosis and treatment may be delayed because of similar abdominal symptoms in children who may be receiving radiation and chemotherapy, or with prolonged ileus. Two children operated on for Wilms tumor demonstrate the need for awareness of this potential problem in the postoperative patient.

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Anterior sacral meningocele is a rare entity. It arises from a congenital defect of the sacrum and the coccyx through which herniation of the caudal portion of the meninges and their contents occurs, forming a cyst-like structure. The cystic mass, which lies between the rectum and sacrum, produces a variety of symptoms depending on its size and contents and constitutes a diagnostic problem. A case of anterior sacral meningocele is presented, including the physical signs, differential diagnosis, and the dangers of aspiration or surgical intervention.

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Knowledge of the factors that affect morbidity and mortality in the treatment of congenital malformations of the esophagus should result in better planning of their surgical management with increased likelihood of success. In 39 infants studied, associated anomalies, low birth weight, and postoperative respiratory complications were the factors responsible for morbidity and mortality. Infants with associated anomalies had a longer hospitalization than those with none, a mean of 17 vs 12 days.

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An infant presented with congenital hemihypertrophy, hepatomegaly, and a low thoracic paraspinal mass. Liver scan showed multiple defects in the uptake of radioisotope. Surgical exploration revealed multiple infantile hemangioendotheliomas of the liver and a paraspinal hemangioendothelioma. In review of 69 reported cases of infantile hemangioendothelioma of the liver and viscera, there has been no previous note of hemihypertrophy associated with this abnormality.

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