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Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists' experience and attitude towards patients' out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons' experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients' choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients' preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.

Hyaluronate carboxymethylcellulose (Seprafilm; Genzyme Corp., Cambridge, MA) has been demonstrated to be safe and efficacious for the prevention of abdominal and pelvic adhesions; however, information is scarce regarding its use in children and adolescents. We wanted to characterize our experience with Seprafilm in a pediatric surgical population. After Institutional Review Board approval, we searched our hospital and pediatric surgery database for cases in which Seprafilm was used and retrospectively reviewed medical records for demographic and clinical information. Between July 2000 and October 2005, 18 patients had Seprafilm placed. Patients ranged in age from 0.25 to 18 years. Seven patients had not undergone any previous operations. Of patients having undergone prior surgery, the most common preceding intervention was a Ladd's procedure. Seprafilm was applied in a variety of scenarios, the most frequently being adhesiolysis for bowel obstruction. No patient required reoperation for obstruction. Two patients underwent subsequent operations for unrelated reasons; one was noted to have no significant adhesions, but the other had extensive adhesions. No patient demonstrated signs or symptoms of small bowel obstruction, intraperitoneal abscess, or localized inflammatory reaction to Seprafilm. Seprafilm was successfully used in our pediatric surgical population without complications.

Over the past 20 years the clinical paradigms underlying the care of children with congenital diaphragmatic hernia (CDH) have undergone profound changes. The purpose of this work is to provide an historic review of research and clinical studies related to CDH at the University of Florida (UF) and Shands Children's Hospital during the chairmanship of Edward M. Copeland, III, M.D. and to present our current clinical results. During Dr Copeland's tenure survival for newborns symptomatic with CDH treated at UF/Shands Children's Hospital has improved from less than 20 per cent to 85 per cent. Clinical observations have suggested and research studies at UF using a fetal lamb model have confirmed that fetal distress can occur late in gestation, which may predispose infants with CDH to pulmonary hypertension. However, our patient experience has confirmed that the most significant cause of mortality in human infants is not pulmonary hypertension but iatrogenic injury to their hypoplastic lungs. Strict avoidance of barotrauma in these babies has been the most important clinical advance during these two decades. Significant clinical and research problems remain including defining optimal prenatal care, management of complications during the first few weeks of life, and development of strategies to accelerate lung growth. Dramatic improvements in survival have resulted in children who manifest a number of clinical problems that were not evident when most of these patients died early in infancy. Our experience at Shand's Children's Hospital/UF indicates that feeding problems, respiratory infections, and management of subtle or overt neurologic complications may become major issues for some of these survivors and their families.

Neuroblastoma is the most common extracranial tumor of childhood. This tumor is associated with alterations in apoptosis and is affected by various growth factors and cytokines. In this short review we will discuss recent findings in our laboratory where we have been studying a cell culture model of neuroblastoma.

The speed and use of small watercraft have increased dramatically in recent years. We report our experience with pediatric trauma resulting from small watercraft accidents. We conducted a retrospective chart review including all children admitted with injuries sustained in small watercraft accidents. Sixteen children were included; nine were injured in jet ski accidents and seven in accidents involving other craft. Jet ski accidents tended to result in more serious injuries (closed-head injuries, hollow and solid viscus injuries, chest trauma, spinal injuries leading to paralysis, and death) than those sustained in accidents with small boats. Skin and soft-tissue injuries and long-bone fractures were the most frequent injuries following accidents with other small boats. Six of eight children (75%) injured on jet skis required operative interventions. Only three of seven (43%) children in other watercraft accidents required surgery (P < 0.05 jet ski vs other watercraft). When compared with children injured in accidents involving small boats those involved in jet ski accidents tended to have more serious injuries and require operative intervention more frequently. A high index of suspicion for serious injuries must be maintained when evaluating children with this mechanism of injury.

Involvement of the inferior vena cava (IVC) by hepatic tumors, although uncommon, is considered to be unresectable by standard surgical techniques. Recent advances in hepatic surgery have made combined hepatic and vena caval resection possible. The purpose of this study is to describe the surgical techniques and early results of combined resection of the liver and IVC. From 1997 to 2000, 11 patients underwent resection of the IVC along with four to seven liver segments. Resections were carried out for hepatocellular carcinoma (four); colorectal metastases (four); and hepatoblastoma, gastrointestinal stromal tumor metastases, and squamous cell carcinoma in one patient each. Ex vivo procedures were performed twice, and total vascular isolation was used in the nine other cases. The IVC was reconstructed with ringed Gore-Tex tube graft (five), primarily (five), or with Gore-Tex patches (one). There were two early deaths: one from liver failure at 3 weeks and one from sepsis secondary to a perforated segment of small bowel 4 months postresection. One patient with a gastrointestinal stromal tumor died at 32 months of recurrent tumor and one patient with hepatocellular carcinoma is alive with recurrent tumor at 16 months. The remaining patients are alive and disease free with follow-up ranging from 3 to 40 months without evidence of IVC occlusion. Combined resection of the liver and IVC is a formidable undertaking with substantial surgical risk. However, this aggressive surgical approach offers a chance for cure in patients with tumors involving the IVC that would otherwise have a dismal prognosis.