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Several conditions in children produce a mass effect within one hemithorax, which may be life threatening. The different radiographic appearances of these conditions provide a basis on which they can be classified. The three major categories include a large cystic hemithorax, a large lucent hemithorax, and a large opaque hemithorax. Some disorders may be seen within more than one major group. Within the large cystic hemithorax group, congenital cystic adenomatoid malformation and congenital diaphragmatic hernia may be life-threatening conditions that require emergency surgery. The large lucent hemithorax is usually caused by pneumothorax, partial bronchial occlusion, or compensatory hyperinflation of the unobstructed lung. The majority of cases within the large opaque hemithorax group involve pleural fluid collections. Because many conditions that cause a mass effect require intervention or surgery, accurate interpretation of the plain chest radiograph is essential for an early diagnosis. Classification of radiographic features into these three groups often allows accurate diagnosis without additional studies.

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I-V). The age range of the patients was 6 months to 17 years (mean +/- SE; 11 +/- 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 +/- 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 +/- 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 +/- 8 days. Of the three remaining grade IV injuries two were healed by 173 +/- 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 +/- 8 days postinjury (range 11-217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.

The clinical course of a 31-month-old patient with advanced (stage IV) rhabdoid tumor of the kidney (RTK) and an analysis of treatment variables that may impact survival are presented. Treatment included complete resection of abdominal disease, radiation therapy to the abdomen and chest, and chemotherapy on a schedule of dose intensification by reduction of the interval between cycles. Inclusion of doxorubicin in treatment was associated with survival among patients in published series (P = 0.002). The patient was in continuous complete remission 60 months from diagnosis. Stage IV rhabdoid tumor of the kidney can be effectively treated with intensive multimodal therapy. Doxorubicin may be an important component of a successful therapeutic regimen.

Pleural empyema represents an infection of the pleural space caused either by direct introduction of bacteria, as in cases of surgery or trauma, or by indirect contamination from infections in adjacent organs, as in cases of pneumonia or subphrenic abscesses. In children the most common source of empyema is pneumonia, while postoperative infection represents the second most common etiology. Our understanding of the pathophysiology of empyema was advanced by the conclusions of the Graham Commission in 1918. The recommendations for treatment of empyema made by this group still form the basis of our treatment strategies today: The infected fluid within the pleural space must be completely drained. This should be performed early in the development of empyema using closed techniques, while in late stage empyema, open drainage may be more effective. Chronic empyema should be avoided by early therapy of the infected pleural space. Careful attention should be paid to the nutritional status of the patient [1].

To assess the impact of helmet use on the pattern, and severity of pediatric equestrian injuries.A prospective observational study of all children less than 15 years of age who were brought to the University of Virginia children's Emergency Department with horse-related injuries.During the two-year period of the study, 32 children were evaluated. Two children were injured when a horse stepped on them. Thirty children fell from or were thrown from a horse. Of these, 20 were wearing a helmet. Head injuries were more frequent in those patients not wearing helmets. The mean Modified Injury Severity Scale (MISS) score for riders without a helmet (12.9) was significantly higher (more severe) than that for helmeted riders (2.8). All three patients with a Glascow Coma Score15 on arrival were not wearing a helmet at the time of injury. The frequency of hospitalization was significantly higher for those not wearing a helmet. Compared with other common mechanisms of childhood injury the mean Modified Injury Severity Scale score of injured riders was exceeded only by that of pedestrians struck by a car.Equestrian injuries are more severe than those suffered from other common pediatric mechanisms. Helmet use is associated with decreased frequency and severity of central nervous system injury.

Although thoracoscopy was initially reported in 1910, the first specific report in children came in 1976. Over the past 15 years, reports from a small number of institutions have described experience with this technique. For the past 2 years, as pediatric surgeons have become involved with minimally invasive abdominal surgery, there has been renewed interest in the application of endoscopy for thoracic disorders in children, the most common indication for thoracoscopy is evaluation of mediastinal masses. Other common indications include evaluation of localized or diffuse pneumonia, management of pleural diseases such as refractory empyema, and management of recurrent pneumothorax, with either pleurodesis or excision of subpleural blebs.

After extracorporeal perfusion some patients develop evidence of cytomegalovirus (CMV) infection. It is proposed that antigenically stimulated donor and recipient leukocytes may divide and activate latent CMV associated with leukocytes. To test this hypothesis, alternate patients were perfused with leukocyte-depleted or whole blood (controls). Four of six controls who were CMV antibody negative preoperatively seroconverted after perfusion. Virus was recovered from the blood of three and from the urine of two of these patients. One of four controls who were seropositive preoperatively developed a significant titer rise. Only one of eight patients perfused with leukocyte poor blond who were seronegative prior to surgery developed a viremia and became antibody positive; another manifested a viruria but remained antibody negative. These findings are consistent with the proposed hypothesis and suggest a means for reducing transfusion-associated CMV infections.

Progressive encephalopathy with characteristic clinical features and electroencephalographic findings has been reported many times in adult patients treated with maintenance hemodialysis. Two children with chronic renal failure developed a similar encephalopathy prior to their, second birthdays and before the initiation of dialysis. Both children required parathyroidectomy for control of severe hyperparathyroidism with persistent hypercalcemia. Slight improvement followed this procedure in one patient. Selected biochemical abnormalities in serum and in brain tissue specimens were compared to those of neurologically unaffected children. Results of these studies suggest that a direct toxic effect of either aluminum or calcium on the brain does not play an etiologic role in this disorder.

Ventral anomalies of accessory pulmonary tissue have been classified as "bronchopulmonary foregut malformations." Between July 1, 1981, and May 31, 1985, 10 children with bronchopulmonary malformations have been cared for on the Pediatric Surgical Service at the University of Virginia. Six patients had bronchogenic cysts, one in an extrathoracic location and one associated with a pulmonary sequestration. Diagnosis was suspected in each case by plain chest radiographs and confirmed by computed tomography scans and ultrasound. Four patients had pulmonary sequestrations, two in association with diaphragmatic hernias. One patient had accessory pulmonary tissue, best classified as a tracheal lobe. Diagnosis in this patient was confirmed by bronchography. Nine patients underwent excision of the malformation without event. In one patient, a bronchogenic cyst was treated successfully by thoracoscopy. Review of the anatomy of these malformations leads to the conclusion that three embryologic events are cardinal in determining their ultimate form: (1) investment of the anomalous pulmonary tissue by the pulmonary artery; (2) the degree of involution of the original foregut communication; and (3) the stage of development leading to pleural investment.

The purpose of this study was to determine if patient-controlled analgesia (PCA) is an effective method of postoperative pain relief for children. Fifteen general surgery patients, aged 11 to 18 years, were treated for pain with PCA. Self-report of pain intensity by the child, parent, and nursing staff and a posttreatment questionnaire were analyzed. The average amount of medication administered by PCA was compared with the amount given to similar group of children treated by traditional administration; overall, the PCA group received less morphine than the traditional group. This study indicates that PCA is a valuable addition to pain management for the pediatric patient.

Cryotherapy, the application of supercool temperatures to living tissue, has proved successful in the treatment of many superficial neoplasms. Recent clinical studies have suggested the efficacy of an aggressive surgical excision of multiple pulmonary metastatic nodules. The current experiments were designed to study the effects of profound cryotherapy upon the pulmonary parenchyma as a preliminary to the use of this modality clinically in patients in whom further pulmonary resection is impossible. Six dogs were subjected to temperatures of -120 degrees C on the visceral pleural surface of the lingula for three successive freeze/thaw cycles. Serial roentgenograms were obtained on all animals and surviving animals were killed between 4 and 28 days following cryotherapy. Radiographically, an infiltrate developed in the region of cryotherapy within 3 to 5 days, clearing completely by 28 days. There was no instance of delayed pneumothorax developing. Histologically, a subpleural hemorrhagic infarct developed in the region of cryotherapy with mesothelial proliferation on the overlying pleural surface. Within 28 days the infarct had resolved to a subpleural fibrous scar with normal surrounding pulmonary parenchyma. These studies demonstrate the safety of profound pulmonary cryotherapy and suggest cautions clinical trials.

Interstitial pneumonitis in immunosuppressed patients demands prompt diagnosis and treatment. In an effort to achieve a simple yet highly accurate method of diagnosis, we have evaluated the usefulness of thoracoscopic examination. Twenty-seven procedures have been performed in 24 patients between the ages of 17 months and 18 years. All patients were immunosuppressed, most for treatment of malignant processes. All procedures have been performed under anesthesia with intravenously administered ketamine, without endotracheal intubation. A definitive diagnosis has been made in every case, with pneumonia due to Pneumocystis carinii being identified in 18 instances. Complications have been minimal and include four minor pneumothoraces, two instances of bleeding, and two instances of prolonged air leak. Mortality attributable to the procedure has been nil, although five patients have died due to their underlying diseases within 30 days of the thoracoscopic procedure. Thoracoscopy has proven to be a rapid and safe technique for providing accurate histologic and bacteriologic diagnoses in these critically ill children.

With advances in equipment design, cryotherapy has been applied increasingly in the management of various integumentary disorders. Recently, endobronchial cryotherapy has been utilized in the treatment of acquired tracheal strictures. To evaluate the effects of cryotherapy upon the esophagus, we cooled the distal esophagus of 12 cats to -70 degrees to -80 degrees C. for 2 minutes with a specially constructed cryoprobe. The animals were put to death in pairs 90 minutes, 4 days, 10 days, 14 days, 28 days, and 42 days following cryotherapy. Immediately prior to sacrifice, all animals were studied with esophageal cinefluoroscopy and esophageal manometrics. All animals tolerated this degree of cryotherapy and gained weight on an ad libitum diet. Manometric studies demonstrated diminished amplitude of peristalsis immediately following cryotherapy, but prompt return to a normal manometric pattern. There was no evidence of esophageal dysfunction on esophageal cinefluoroscopy. Morphologic examination demonstrated superficial ulceration between 4 and 10 days following cryotherapy, with subsequent healing. The esophagus in animals put to death 28 and 42 days following cryotherapy appeared histologically normal. These studies demonstrate the safety of cryotherapy to -70 to -80 degrees C. upon the esophageal wall and suggest investigation of the usefulness of this modality in the treatment of local esophageal webs and strictures.

The clinical features of the multiple mucosal neuromas (MMN) syndrome permit the recognition of these patients and their potential development of the associated medullary thyroid carcinoma (MTC). The distinctive physical appearance caused by the mucosal neuromas, the Marfanoid habitus and, occasionally, the positive family history aid in establishing the diagnosis. Neurogangliomas are frequently present in the gastrointestinal tract of these patients who may have megacolon, constipation and diarrhea. The third instance of the MMN syndrome is reported in the newborn as intestinal obstruction. It is suggested that the syndrome be considered in the differential diagnosis of Hirschsprung's disease and bowel obstruction in the neonate. Serum calcitonin measurements following stimulation by calcium or pentagastrin infusion reliably detect incipient MTC and may be used to select those MMN patients requiring thyroid surgery. Recognition of patients with the MMN syndrome and subsequent calcitonin screening and early surgical intervention will significantly reduce the chance of their developing terminal MTC. All MMN patients with mucosal neuromas or intestinal neurogangliomas should have such evaluations at least yearly. Relatives who are at risk for inheriting this dominant disease should be similarly evaluated, regardless of their normal appearance.

Although the diagnosis of peptic ulcer disease may be difficult in the pediatric age group, this problem is being faced increasingly by the physicians charged with the care of these children. Chronicity of symptoms has been documented in over 50 per cent of the patients demonstrating early peptic ulcers and therefore an aggressive approach to management has been advocated. Although the numbers are small, postgastrectomy syndromes of mechanical and nutritional nature appear less common in the young patient than in adults. Satisfactory growth and development are reported in nearly all series of patients followed after various gastric procedures. Both pyloroplasty and vagotomy and vagotomy and antrectomy appear to be extraordinarily well tolerated by the pediatric patient. Experimental evidence suggests that these patients should enjoy normal growth and development.

Cardiac herniation is an uncommon but rapidly fatal complication of radical pneumonectomy. Although operative correction is simple, a successful clinical outcome requires early diagnosis and thoracotomy. A patient is described in whom a left-sided cardiac herniation through a pericardial defect occurred following radical pneumonectomy. The diagnosis was suspected by persistent hypotension and radiographic changes. Confirmation of the diagnosis was achieved by thoracoscopy, performed with local anesthesia in the operating room. Immediate thoracotomy resulted in a successful outcome.

Despite better prevention programs and emergency medical care, trauma continues to be the leading cause of death in children. Children present very special anatomic, physiologic, and psychological problems to the emergency room physician, and the spectrum of injury in these young patients may be significantly different from that seen in adult trauma victims. These factors make immediate diagnosis and early appropriate therapy for these young patients imperative to a successful outcome. A few unique forms of injury have been reviewed in this article and their diagnosis and management discussed.

Achalasia of the esophagus is an unusual lesion in childhood and is quite rare under the age of one year. The case of a 3-month-old child with esophageal achalasia treated with a Heller esophagomyotomy is illustrated. Seven previously documented cases of achalasia in children under the age of one year are reviewed and the difficulties of diagnosing this lesion in childhood are discussed.

The development of chylothorax is a serious and often life-threatening clinical entity. Optimal management of this problem has not been well defined to date. We reviewed our experience with chylothorax in patients of all ages during the past 10 years. Ages ranged from 2 days to 69 years. The etiologies were traumatic in 17 and congenital or idiopathic in three. Six patients (five infants) were treated nonoperatively with either repeated thoracenteses or chest tube drainage. Fourteen patients (11 infants) underwent operative treatment: transthoracic thoracic duct ligation (five patients), pleuroperitoneal shunting (seven), pleuroperitoneal shunting combined with reoperation on a patient with congenital heart disease (one), and reoperation alone on a patient with congenital heart disease (one). Duration of preoperative therapy ranged from 9 days to 2 months (average 3.3 weeks). Five of six (83.3%) patients treated nonoperatively died. Of the surgically treated group, only two of 14 (14.3%) died, and 11 of the 12 survivors had resolution of the chylothorax and immediate clinical improvement. Our experience suggests that both pediatric and adult patients respond poorly to nonoperative treatment of chylothorax and that this treatment has a high mortality rate. Post-traumatic and congenital chylothorax should be treated operatively after a limited trial (1 to 2 weeks) of nonoperative therapy. Pleuroperitoneal shunting may offer a reasonable and effective alternative to thoracotomy and thoracic duct ligation.

Three cases of traumatic perforation and pseudodiverticulum of the hypopharynx in newborn infants are presented. This lesion may be encountered with increasing frequency as a result of the more aggressive management of newborn infants with respiratory distress. Early recognition of this complication is essential to successful therapy. Appropriate management includes local drainage, treatment with antibiotics, and use of a nasogastric tube or gastrostomy to provide a safe route for intestinal alimentation.

Two cases of acquired colonic atresia subsequent to necrotizing enterocolitis (ischemic enteropathy) in the neonatal period are reported. These infants were noted to have complete atresia of the colon in the region of the splenic flexure 8 and 11 weeks after small bowel resection and ileostomy formation. Recognition of this and other late sequelae of ischemic enterocolitis becomes critical to the successful outcome of these patients as survival rates increase.

The introduction of absorbable polyglycolic or polyglactin mesh has added a new dimension to splenic repair. Three patients with splenic disruption caused by blunt abdominal trauma underwent splenic wrapping with polyglactin mesh at the University of Virginia. The technique is described in detail. In all three instances, the spleen was saved, and postoperative nuclear medicine scans confirmed continued splenic function.

Cell proliferation is associated with tissue polyamine synthesis. Animal studies demonstrate increase in hepatic putrescine, spermidine, and spermine after surgical or chemical liver injury, and have been interpreted to indicate hepatic regeneration. Whole blood polyamines reflect hepatic polyamine changes and were, therefore, measured serially in 16 infants and children with giant cell hepatitis (6), chronic active hepatitis (6), fructosemia (1), and after hepatectomy (3). After hepatectomy the patients' spermidine levels increased 2.5-5.5 times normal, spermine 1.5-3.5. Similar elevations were seen initially in patients with hepatocellular injury, which returned to normal with biochemical resolution of their disease. Blood polyamines were normal-to-elevated in 6 patients with chronic active hepatitis, increased with steroid therapy and returned to normal with continued therapy, in only 1 patient after biochemical remission. Among patients with active disease the mean blood spermidine was 18.87nm/ml (8.31±3.92), spermine 8.6nm/ml (4.98±3.12), spermidine:spermlne 2.28 (1.67±1.26). All patients demonstrated a peak spermidine:spermine ratio greater than 4 except two who expired with liver failure. These data suggest that the course of hepatic injury and regeneration might be monitored through serial measurement of blood polyamines. A deficient polyamine response or persistent polyamine elevation may imply a poor prognosis.