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BACKGROUND: Acute appendicitis is the most common abdominal condition necessitating urgent surgical intervention in the United States. The objective of this study was to determine if interval laparoscopic appendectomy after initial nonoperative treatment for late appendicitis presenting as an appendiceal mass is a safe alternative to immediate appendectomy. METHODS: Thirty two consecutive patients (aged 16-74 years) during a 5-year period presented with appendiceal mass. Seventeen received initial nonsurgical treatment followed by interval laparoscopic appendectomy (aged 16-60 years; group 1). Fifteen underwent immediate appendectomy (aged 16-74 years; group 2). RESULTS: All patients in the interval laparoscopic appendectomy group improved with initial therapy and underwent surgery an average of 4.9 months later. Although the operative time and the complication rate were similar between groups 1 and 2, the time to return to baseline activities was significantly less in group 1 after adjusting for age (p = 0.02 or less). CONCLUSIONS: Interval laparoscopic appendectomy is safe in patients with chronic appendicitis and allows for judicious diagnostic evaluation of the appendiceal mass and planned surgery under controlled conditions.

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Elevated concentrations of eicosanoids have been reported in bronchoalveolar lavage fluid (BALF) and blood of infants with persistent pulmonary hypertension (PPHN), thereby indicating their potential role in its pathophysiology. Extracorporeal membrane oxygenation (ECMO) has improved the outcome in selected infants with PPHN. We hypothesized that ECMO, by alleviating lung injury, would be associated with decreased eicosanoid production and clinical improvement. Twenty-two newborns with PPHN treated with either ECMO or conventional means were studied. Concentrations of TxB2, 6-keto-PGF1 alpha, PGD2, PGE2, LTB4, and LTE4 were serially measured in BALF. Elevated concentrations of all eicosanoids measured were observed in all infants with PPHN at the initiation of ECMO. Eicosanoid concentrations decreased in all infants with a good clinical outcome after ECMO, but they remained elevated in those with a poor outcome. In patients with less severe PPHN, not requiring ECMO, lower concentrations of eicosanoids were observed at initiation of therapy. Eicosanoid levels increased or did not change over the course of conventional treatment. We conclude that eicosanoids are present in high concentrations in infants with PPHN. Iatrogenic factors, including oxygen and barotrauma, appear to correlate with their concentrations. Removal of these factors is associated with decreased production of mediators and clinical improvement.

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Internal heat flow from radioactive decay in Triton's interior along with absorbed thermal energy from Neptune total 5 to 20 percent of the insolation absorbed by Triton, thus comprising a significant fraction of Triton's surface energy balance. These additional energy inputs can raise Triton's surface temperature between approximately 0.5 and 1.5 K above that possible with absorbed sunlight alone, resulting in an increase of about a factor of approximately 1.5 to 2.5 in Triton's basal atmospheric pressure. If Triton's internal heat flow is concentrated in some areas, as is likely, local effects such as enhanced sublimation with subsequent modification of albedo could be quite large. Furthermore, indications of recent global albedo change on Triton suggest that Triton's surface temperature and pressure may not now be in steady state, further suggesting that atmospheric pressure on Triton was as much as ten times higher in the recent past.

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Venous access devices are an option offered to pediatric oncology patients to make their frequent blood sampling and intravenous therapy more tolerable. To determine the advantages and disadvantages of using these devices, a study comparing Mediport and Broviac catheters was conducted from August 1985 to August 1987 at The Children's Hospital, Denver, Colorado. This report will analyze results of the patient-parent acceptance questionnaire employed in that study. Overall, both the patients and their parents were very positive about the devices. Daily care of the Broviac and pain associated with accessing the Mediport were the only uniformly negative factors we encountered. These problems became unimportant when compared to the advantage of eliminating peripheral venipuncture.

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We reviewed 187 cases of documented neonatal necrotizing enterocolitis (NEC) from 1976 to 1988. Of these patients, 111 infants underwent celiotomy for acute surgical complications. The following protocol of operative indications was employed: pneumoperitoneum, localized mass, abdominal wall erythema, portal venous air, and clinical deterioration, singly or in any combination. Clinical deterioration was defined as falling platelet count, rising or falling white blood cell count, left shift in the myeloid series, persistently or progressively low pH, and increasing frequency of apnea or bradycardia. Overall mortality was 15% (28 of 187). For the patients who underwent celiotomy, all had histologic confirmation of NEC. Ninety-five had localized disease, and 16 had diffuse disease. All of the former had resection and diverting enterostomy with 85 (89.5%) surviving; none with diffuse disease survived, P less than 0.0001. Forty-one infants with NEC weighed less than 1,000 g; 25 underwent surgery and 15 (60%) survived. Fifty-one of the 159 surviving neonates (32%) developed intestinal strictures. All neonates with strictures have had resection and successful reconstruction of their gastrointestinal tract. These indications and surgical principles resulted in a high degree of diagnostic accuracy and a low degree of surgical mortality.

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The Fogarty balloon catheter is a useful adjunct in removing aspirated foreign bodies, but its use is not without risks. A case is presented of Fogarty catheter disruption while attempting to remove a foreign body. The resulting debris in the distal airway was inaccessible to bronchoscopic retrieval. An effective treatment plan is outlined to deal with this problem.

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From 1976 to 1986 inclusive, 122 patients were cared for with Hirschsprung's disease. Sixteen of these were treated for total colonic aganglionosis, with or without small bowel involvement. The male to female ratio was 2.2:1. Two children died prior to definitive surgical therapy and two others were transferred following initial therapy. Twelve children underwent Martin's procedure with a 0% mortality rate and an 81.8% morbidity rate. This study would indicate, as do others, that even though the Martin procedure can safely be performed, the long-term results require close scrutiny. A re-evaluation of this procedure and its alternatives is necessary in order to improve long-term results.

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Long term venous access devices have become an important part of the standard care for children with malignant diseases requiring chemotherapy. A prospective nonrandomized study was conducted between January 1985 and January 1987 examining complications, child and parental acceptance and costs between totally implantable venous access devices (ports) and externally exiting catheters. Fifty ports were placed in 49 patients who had a median age of ten years; median implant time was 350 days. Forty-one catheters were placed in 39 patients who had a median age of eight years; median implant time was 365 days. Both devices provided equivalent venous access. Although catheters were initially less expensive, the cost for both devices was comparable by the six month point. Beyond this time, an increasing savings was realized when the port was used. Catheter device complications occurred 14 times compared with seven with ports (p less than 0.02). There were 15 infectious complications with catheters compared with seven with ports (p less than 0.01). Child and parental acceptance questionnaires indicated that the ports were easier to care for and more readily accepted in children older than 11 years than were catheters (p less than 0.001). Totally implanted reservoirs are effective alternatives to external catheters for venous access in children with cancer.

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Multiple level esophageal pH studies were performed in 23 neurologically damaged infants and children for evaluation of gastroesophageal reflux (GER) and feeding difficulties. The patients were placed in one of three anatomic groups based on the extent of their neurologic injury. Seven children had an acute cerebral injury due to closed head trauma or infections. Six patients with perinatal asphyxia or progressive encephalopathy had a global CNS insult. Eight children with CNS malformations or intraventricular hemorrhage had subacute cerebral damage. Two patients with generalized seizure disorders could not be anatomically classified. In all groups, abnormalities detected at the distal esophagus were also noted at more proximal levels. The middle esophageal probe demonstrated a significant difference (P less than .02) for the longest reflux episode between patients with subacute cerebral injury and those with a global insult. The difference (P less than .02) for the longest reflux episode detected by the distal pH sensor in globally damaged children compared with those with acute cerebral injury also persisted at the middle and proximal esophageal levels. Comparing these same groups, a difference (P less than .02) in acid clearance time and percentage of time pH less than 4 was noted only at the proximal esophageal level. Only the middle and proximal pH probes detected differences (P less than .02) for acid clearance time between patients with both types of cerebral damage and those with a global injury. In infants and children with CNS damage and suspected GER, monitoring the proximal and middle esophageal pH provides important information not detected by the distal esophageal sensor.(ABSTRACT TRUNCATED AT 250 WORDS)

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Seventy-one extended multiple-level esophageal pH studies were performed in 61 infants and children suspected of having gastroesophageal reflux (GER). The patients were placed in one of six clinical groups based on their presenting symptomatology. They were classified as "normals" or "refluxers" based on a reflux score calculated from a pediatric modification of the Johnson and DeMeester distal esophageal pH criteria. For the total group, excluding postoperative patients, all differences noted in the distal esophagus between normals and refluxers persisted at the middle and proximal esophageal levels (P less than .001). Significant differences between normal and reflux patients were noted at all levels in the central nervous system damage and postoperative groups. Only the middle esophageal probe detected differences for all variables in the failure to thrive group (P less than .01). In the esophageal atresia group the middle level sensor detected differences in all parameters studied and the proximal sensor noted differences in three of the four parameters (P less than .01). Significant differences between normals and refluxers in the apnea group were best demonstrated in the proximal esophagus. There was no benefit in monitoring the pH of the more proximal esophageal levels in patients with esophagitis. Extended four-channel esophageal pH studies were highly effective in detecting clinically important GER. The patterns of reflux in infants and children vary markedly with the presenting symptoms. Distal esophageal pH monitoring may not demonstrate evidence of GER that would otherwise be detected by the middle and proximal esophageal sensors. This new ambulatory outpatient technique of pH monitoring in young patients suspected of having GER provides advantages over the conventional esophageal pH study.

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