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Background/purpose: Despite improvements in the surgical management of biliary atresia, the long-term incidence of progressive liver failure remains high. Because chronic inflammation involving both bile ducts and liver parenchyma contributes to the pathology, the authors have hypothesized that the liver damage may be altered using immunosuppressive therapy. The aim of this study was to examine the safety and efficacy of long-term steroid therapy in patients with biliary atresia., Methods: A retrospective analysis of all patients with biliary atresia treated with an hepatoportoenterostomy and postoperative steroid therapy at our 3 institutions was undertaken. Patients were treated uniformly with immunosuppressive doses of oral steroids for a minimum of 6 weeks after surgery., Results: Twenty-five infants with biliary atresia were treated with steroid therapy. Overall survival rate was 22 patients (88%) with a mean follow-up period of 50 months. Nineteen patients (76%) became jaundice free with native liver function. Four patients (16%) did not respond to treatment and required transplantation. Age less than 12 weeks was a crucial predictor of success of adjuvant steroid therapy. Cholangitis developed in 8 patients (32%). There were no complications caused by steroid therapy., Conclusions: Steroid administration at immunosuppressive doses markedly improves the clinical outcome within the first 5 years after surgery as measured by jaundice-free status and survival without liver transplantation when compared with concurrent reports. These results suggest that immunosuppressive therapy is safe and has a positive impact on the clinical course of this disease. However, a randomized study is needed to ultimately prove such an hypothesis.

Minimal access pediatric surgery has developed more slowly than its adult counterpart for several reasons. Surgical pain and perioperative stress associated with open procedures have been underappreciated in children. Appropriately sized instrumentation was slow to develop because the focus of the marketplace was the adult. The advanced techniques required for pediatric laparoscopic procedures are associated with a relatively long learning curve. Reports documenting the safety, efficacy, and cost effectiveness of pediatric endosurgery are fueling a rapid evolution in instrumentation and minimal access procedures for children. This evolution will eventually influence most pediatric surgical procedures, changing the paradigm of the practice of pediatric surgery. It is the pediatric patient who has the most to gain from these alterations in their surgical care with less pain, decreased hospital days, and earlier return to regular activities.

Surgeons have at their disposal multiple options for providing enteral access in a myriad of circumstances. This article reviews the techniques for surgical placement of enteral access as well as the indications, benefits, and complications for each procedure. The feeding tubes commonly available are described, and considerations involved in the choice of procedure are discussed.

Prior to receiving briefly lateralized presentations of ambiguous visual patterns (Rorschach inkblots), 28 normal right-handed males heard two words, each describing a different interpretation of the pattern, e.g., one word might describe an interpretation based on attending to shapes or forms (form choices) and the other might describe an interpretation based on attending to chromatic color (e.g., color choices). Color choices were more frequent than form choices on left-hemisphere (LH) presentations of the patterns, and form choices were more frequent than color choices on right-hemisphere (RH) presentations. These results were interpreted as consistent with the theory that the LH's favored mental representation is semantic (i.e., frequent choices of concepts associated with names of colors in the patterns) and the RH's favored representation is imaginal (i.e., frequent choices of concepts associated with difficult-to-label forms in the patterns).