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Procedures and outcomes for pediatric esophageal foreign body removal were analyzed. Traditional methods of battery removal were compared with a magnetic tip orogastric tube (MtOGT). A single institution retrospective review from 1997 to 2014 of pediatric patients with esophageal foreign bodies was performed. Balloon extraction with fluoroscopy (performed in 173 patients with 91% success), flexible endoscopy (92% success in 102 patients), and rigid esophagoscopy (95% in 38 patients) had excellent success rates. A MtOGT had 100 per cent success in six disc battery patients, when other methods were more likely to fail, and was the fastest. Power analysis suggested 20 patients in the MtOGT group would be needed for significant savings in procedural time. Thirty-two per cent of all foreign bodies and 95 per cent of batteries had complications (P = 0.002) because of the foreign body. Overall, 1.2 per cent had severe complications, whereas 10 per cent of batteries had severe complications (P = 0.04). Each technique if applied appropriately can be a reasonable option for esophageal foreign body removal. Magnetic tip orogastric tubes used to extract ferromagnetic objects like disc batteries had the shortest procedure time and highest success rate although it was not statistically significant. Disc batteries require emergent removal and have a significant complication rate.

Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P < 0.0001) and per intensive care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P < 0.0001). The work day spent in direct patient care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent (P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day (P = 0.0004). Reported duty hour violations decreased 58 per cent (P < 0.0001). American Board of Surgery in Training exam scores trended up, and estimates of departmental annual financial savings range from $66,598 to $273,141 per year. Significant improvements occur with surgeon designed EMR tools like the RR. Hospitals and EMR companies should pair interested surgeons with health information technology developers to facilitate EMR enhancements. Improvements like RRs can have broad ranging, multidisciplinary impact and should be standard in all EMRs used for inpatient care at academic medical centers.

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1-18) placed on ECMO in the last 15 years (1999-2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2-16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23-122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2-6). The average number of days on the ventilator was 15 (range 4-27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1-15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.

A cutaneous ciliated cyst is a rare entity found predominantly in the lower extremities and perineal region of young females. Although initially described by Hess in 1890, the present day term, "cutaneous ciliated cyst," was proposed by Farmer in 1978 and includes a wide array of cyst types. Despite their typical female predominance and location, many have described cutaneous ciliated cysts in males and atypical locations. In addition, Mullerian cysts in the posterior mediastinum and the retroperitoneum have been reported. To date, only 40 cases have been reported in the literature of a Mullerian-type, cutaneous ciliated cyst. Here, we report a case of 13-year-old female with one in the gluteal cleft, initially presenting as a pilonidal cyst. We also discuss the differential diagnosis of pediatric sacrococcygeal lesions and pathogenesis of a Mullerian-type, cutaneous ciliated cyst.

The serial transverse enteroplasty procedure (STEP) was introduced as a bowel-lengthening procedure to reduce complications related to short bowel syndrome (SBS). Although some have described it as a useful adjunct to the Bianci procedure, others have acknowledged it as a primary procedure. We present a case of jejunal atresia in which two STEP procedures were performed 7 months apart to increase small bowel length. A 1-day-old, term girl presented with a known bowel obstruction diagnosed in utero. A laparotomy revealed a Type IIIb jejunal atresia with no remaining small bowel or cecum. A STEP procedure with an end jejunostomy and ascending colon mucous fistula lengthened the small bowel from 35 to 50 cm. A repeat procedure 7 months later lengthened it to 89 cm. The STEP procedure results in slower intestinal transit time and increases enterocytes contact with oral intake. We performed it during our initial exploration to increase small bowel size by 30 per cent. A repeat procedure 7 months later increased length to 89 cm. The use of multiple, staged STEP procedures avoided the need for bowel transplantation and long-term total parenteral nutrition dependence, demonstrating its effectiveness as a primary procedure for the surgical management of SBS.

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, was first described by Nora et al. in 1983 as a rare, tumor-like lesion involving the bones of the hands and feet. Popliteal artery pseudoaneursyms in the pediatric population are also unusual. Here, we present a case of a young male with a popliteal artery pseudoaneurysm and distal femur lesion originally thought to be an osteochondroma. A 10-year old, Caucasian male was referred to our facility following an MRI concerning for a popliteal artery pseudoaneurysm. On physical exam, there was a palpable 5 × 5-cm pulsatile mass in the upper popliteal fossa with a normal pulse exam bilaterally. A computed tomographic angiogram demonstrated a 4.5-cm by 1.8-cm by 3.6-cm pseudoaneurysm adherent to a 3.5-cm thick, exostotic lesion of the posterior right femur. He was taken to the operating room for repair of the popliteal pseudoaneurysm and resection of his bone lesion. The final pathology was consistent with a popliteal pseudoaneurysm, osteochondroma, and bizarre parosteal osteochondromatous proliferation (BPOP), otherwise known as Nora's lesion. The location of the lesion and the age of our patient were both atypical for BPOP and to our knowledge, this represents the first report of a resulting popliteal artery pseudoaneurysm., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A term female newborn underwent uncomplicated repair of esophageal atresia with tracheoesophageal fistula (type C) then coarctation of the aorta. Subsequently, she developed symptomatic esophageal strictures, which required serial dilations. In addition, she suffered feeding intolerance from esophageal dysmotility and gastroesophageal reflux disease, necessitating Nissen fundoplication with gastrostomy. At 6 years of age, surveillance esophagogastroduodenoscopy revealed mild stenosis and heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis. This is the second report of heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis following repair of esophageal atresia with tracheoesophageal fistula., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Hypertrophic pyloric stenosis (HPS) is a common cause of nonbilious vomiting in the neonatal period with an incidence of approximately 1 to 3 per 1000 live births. The Ramstedt pyloromyotomy has been the standard treatment since 1912. In 1991, Alain et al. reported a novel approach to HPS using laparoscopy. Since this original description, the laparoscopic pyloromyotomy has become progressively more popular and, in many institutions, has replaced the open approach. Similarly, malrotation is a condition affecting the neonatal population, resulting from incomplete intestinal rotation about the superior mesenteric artery during weeks 10 through 11 of development. If left untreated, it can lead to abnormal mesenteric attachments and a narrowed mesenteric base, placing the patient at risk for midgut volvulus. The standard surgical treatment has been the open Ladd procedure first described in 1932. In 1996, Gross described a minimally invasive procedure to address malrotation. The association of concurrent pyloric stenosis and malrotation has rarely been reported in the pediatric literature. This is the first published report of a laparoscopic treatment of HPS and malrotation simultaneously.

Choledochal cysts represent a rare disease in the Western world. We reviewed our recent experience with a case of perforated choledochal cyst, define the currently accepted treatment options, and review the literature of this unusual disease. An 11-month-old girl presented with abdominal pain and distention as well as non-bilious vomiting. Subsequent workup included endoscopic retrograde cholangiopancreatography revealing a perforated type I choledochal cyst. She underwent single-stage excision and reconstruction with a Roux-en-Y hepaticojejunostomy. Perforated choledochal cyst is a rare event, and prompt surgical intervention is warranted. Single-stage cystectomy and Roux-en-Y reconstruction is possible in select patients. A thorough understanding of the pathophysiology, management, and follow-up is required.

The indications for routine exploration of the asymptomatic contralateral groin during pediatric herniorrhaphy remain controversial. Laparoscopy through the open hernia sac has been described as an alternative to this traditional approach and appears to offer some advantages. In deciding whether this technique should be introduced into our clinical practice, we sought to discover whether there was a significant time difference between these two methods and if there were unique complications associated with this approach. We elected to answer this question in a prospective, randomized study. A total of 18 patients completed the study. There were no significant complications in either group. The average total surgical procedure time in the laparoscopy group was 47.5 minutes versus 41 minutes in the traditional group, which is not a statistically significant difference. We conclude from this prospective, randomized pilot study that laparoscopic exploration can be introduced into a pediatric surgical practice without a significant time penalty, and we currently offer it as a reasonable and safe alternative to our patients.

The aim of this project was to review the course of infants referred for consideration of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that, when exceeded, did not provide clinical benefit to the patient. These settings might then be used in defining failure of conventional mechanical ventilation. We reviewed referral records and hospital charts of all infants treated for severe respiratory failure due to meconium aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989. At an inspiratory pressure > 35 cm H2O, 75% (43/57) of patients eventually required ECMO, and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure was > or = 40 cm H2O, 39/49 patients required ECMO, and 30% (3/10) of those not treated with ECMO died. Once the inspiratory pressure was > 45 cm H2O, 91% (29/32) of patients required ECMO, and only one third of those not treated with ECMO survived. Although the limitations for conventional therapy suggested in this paper may be helpful to clinicians, each center needs to establish guidelines for maximal conventional ventilator support. If these guidelines are clearly defined, alternative methods of therapy can be used once these criteria are achieved.

A variety of forces are reshaping the traditional relationship between physicians and their patients. One consequence of this reform movement will be increased responsibility of the pediatrician to evaluate children with surgical diseases. Pediatricians also will be encouraged to do more of the minor surgical procedures themselves. It is not clear how academic pediatric surgeons should adapt to these changes to assure that the general pediatrician is equipped with the skills to handle this increased responsibility. One obvious solution would be to have the pediatrician in training rotate on the pediatric surgery service. The authors have considered these issues at their institution, and thus became interested in learning the status of pediatric surgical rotations by pediatric house staff in this country. A survey was distributed to the 221 accredited pediatric training programs in this country, and 143 individuals responded. Only thirty-five of these programs require a rotation on pediatric surgery. Eighty-six programs offer it as an elective, but only a minority of house staff takes it. The most disturbing aspect of the survey was the 28 of the programs had required a pediatric surgical rotation in the past but had eliminated it. The most common reasons given for this action were the poor educational content of the rotation and the labor requirements of the pediatric service. Based on the survey, the authors believe that it is unlikely that mandatory rotations on pediatric surgery will be begun in pediatric training curriculums. If pediatric surgeons wish to be involved in training pediatricians, they will need to address the educational content of their electives to meet the changing educational needs of the pediatricians.

Since 1991, laparoscopic cholecystectomy has been utilized in children with sickle cell disease, predominantly because of the decreased pain and shorter hospitalization. We believe that outpatient laparoscopic cholecystectomy or even a 24 hour hospitalization is not indicated in the patient with sickle cell disease. Perioperative complications include bleeding diathesis, vaso-occlusive phenomena, and delayed hemolytic transfusion reactions, although clotting parameters can be normal.

Volvulus of the transverse colon is rare in the pediatric population. We present the tenth known case of a volvulus of the transverse colon in a child. A barium enema demonstrated the bird beak appearance of the colon and showed an air-contrast mirror image in the proximal end. The 360 degrees volvulus found at surgery was treated successfully by detorsion of the bowel.

The differential diagnosis of cervical cysts in children includes common entities such as branchial cleft cysts, thyroglossal duct cysts, and cystic hygromas. Congenital thymic cysts are uncommon and often misdiagnosed as either branchial cleft cysts or cystic hygromas. However, they may have an appearance on CT that can be characteristic. The course of the descent of embryologic thymic tissue in the neck to the mediastinum indicates the potential site of deposition of an ectopic cervical thymic cyst. In a child, a cystic lesion that has an intimate relationship to the carotid sheath is likely to be a thymic cyst. Of the approximately 100 cases of vestigial cervical thymus or thymic cysts that have been reported in children, only 5 cases of a persistent thymopharyngeal duct cyst have been described [1-5]. In two of these five, the persistent thymopharyngeal duct cyst was demonstrated by CT [1,2]. We report one additional case of a cervical thymic cyst and one case of a persistent thymopharyngeal duct cyst both depicted by CT.

Objective: The authors describe the use of interferon-alpha-2a (IFN-alpha-2a) in the treatment of complex hemangiomas and review the role of interferon (IFN) in this example of an angiogenic disease., Summary Background Data: Hemangiomas are the most frequent tumors of infants and children. They grow rapidly for 6 to 8 months and then resolve over a period of years. Approximately 5% produce life-, sight-, or limb-threatening complications, with mortality rates between 20% and 50%. Aggressive therapy with steroids, arterial ligation or embolization, or surgery has been used in these situations with variable results and high morbidity. Recently, IFN-alpha was found to be effective treatment in these complex hemangiomas., Methods: Four infants and one child were treated with IFN-alpha-2a at an initial subcutaneous dose of 1 million units/m2/day and a sustained dose of 3 million units/m2/day for 5 to 11 months. Appropriate laboratory values were monitored and adverse reactions and ultimate response to therapy were recorded., Results: Two patients experienced minor complications that were managed easily. Three patients had total or near-total regression of the hemangioma, one had partial (50%) regression, and one had stabilization but no regression after an average of 7.1 months of IFN therapy., Conclusion: Interferon-alpha inhibits angiogenesis and endothelial cell migration and proliferation in vitro. The patients in this study add to the growing number who have benefited from IFN therapy. As such, IFN-alpha should be considered as a first-line agent in treating complex hemangiomas of infants and children.

Proteus syndrome (PS) is a congenital disorder manifesting with severe deformities, the salient features being gigantism and vascular tumors. The disorder is poorly understood, and there has been much discrepancy in the terminology regarding the vascular tumors in PS. The purpose of this study was to elucidate the histogenesis of these tumors by correlating microscopic observations with immunohistologic information. The value of immunoperoxidase studies in the pathologic evaluation of PS was also assessed. Fourteen formalin-fixed, paraffin-embedded tissue specimens obtained from vascular tumors of six children with PS were stained with Ulex europaeus agglutinin I (UEA-I) lectin and the following immunohistochemical reagents: anti-factor VIII-related antigen (FVIII-RAg) and anti-CD34. The tumors showed varied proportions of vascular, lipomatous, and fibrous tissue components consistent with vascular hamartomas. The predominant vascular channels of the tumors were morphologically consistent with lymphatic vessels. Immunostaining of the endothelium of these vessels was most consistently positive with UEA-I lectin. Although a color reaction product was present in small vessels and some larger blood vessels, anti-CD34 immunostaining spared the lumens of lymphatic channels. In addition, a striking population of dendritic spindle cells was noted with the anti-CD34 but was unnoticed with the other reagents. We concluded that the vascular tumors of PS are primarily lymphatic hamartomas. The spindle cells noted with anti-CD34 immunostaining may relate to angiogenesis and need further delineation.

Giant vascular neoplasms in neonates generally require aggressive medical or surgical therapy for treatment of complications. Steroids, chemotherapy, embolization, radiation, and surgery have all been used with short-term beneficial and sometimes unknown long-term side effects. A new modality of treatment, alpha-interferon, has recently been described. The majority of hemangiomas in children involute by 8 years of age. Occasionally, hemangiomas can endanger vital structures and are associated with a consumption coagulopathy and thrombocytopenia (Kasabach-Merritt Syndrome). These hemangiomas occasionally do not respond to steroids, radiation therapy, cytotoxic drugs, or embolization. The mortality rates approach 50% in nonresponders. Alpha-interferon has been used in these children with life-threatening complications of hemangiomas with relief of symptoms. This case illustrates the potential use of alpha-interferon in the management of giant hemangiomas in children. This emerging form of biological therapy avoids the risks of radiation therapy, embolization, and surgery with only minimal side effects.

A case of a strangulated omental hernia detected by a scrotal scan is presented. This may be the first report in which the scrotal scan showed diffuse increased isotope accumulation throughout the hemiscrotum.

The congenital hamartomatous syndrome known as the "Proteus syndrome" (PS) manifests itself with regional giantism, lymphangiomatous hamartomas, and other variable features. Review of the medical literature shows approximately 50 cases reported to date. Since this syndrome has only recently been defined, the management of these patients has been speculative and often children are not treated. This report summarizes the characteristics of the PS and presents eight additional cases. All of the eight children had regional giantism with macrodactyly and skeletal hypertrophy. Asymmetrical leg length was pronounced in five children. All children had large lymphangiomas, the majority of which involved the trunk. Three of the children have been followed through adolescence, two into late childhood, and three into early childhood. In contrast to previous reports, we believe that early surgical reconstruction is necessary to reduce deformities due to the giantism and the large hamartomas. During extensive excisions, residual abnormal tissue is often needed in the reconstruction and it is not unusual for postoperative leakage of lymph to be prolonged. All of the children in this series have benefited both physically and emotionally from extensive surgical reconstruction.

A 19-month-old black girl had a radical nephrectomy for a Wilms' tumor that contained areas of epithelium indistinguishable from renal cell carcinoma. She was treated with chemotherapy but subsequently had pulmonary metastases develop and massive abdominal recurrence. The recurrent tumor was histologically renal cell carcinoma with no identifiable Wilms' tumor elements. The child died with recurrent and metastatic tumor 13 months after nephrectomy. Pathologic, immunoperoxidase, and flow cytometric studies of this unusual case are presented.

Foreign bodies in the female genital tract are well recognized as a cause of pain, discharge, secretions, and infection. In the small child, the presence of a vaginal discharge is usually associated with either a common object which has been inserted or sexual abuse complicated by a sexually transmitted disease. A 3-year-old child presented with a recurrent labial secretion and drainage due to an unusual foreign body. It was only during a second operation that the possibility of a foreign body was entertained, and diagnostic testing was begun. A third operation permitted removal of the foreign body, a large bone probably of animal origin. The fistula tract was closed after a colostomy was performed. This represents the first reported case of a rectovulvar fistula not of a congenital nature.

We reviewed the outcome of all infants referred to, and accepted in, our extracorporeal membrane oxygenation (ECMO) program during a 52-month period. One hundred sixty-seven referrals, representing 158 infants and nine mothers who had not yet delivered their infants, were accepted. Eighteen infants (11.3% of all neonates transported) died before leaving the referring hospital, during transport, or shortly after admission to our unit. Contraindications to ECMO excluded 17 (10.1%) of the 167 referrals. Sixty-two infants (37.1%) initially did not meet ECMO criteria. Two died before ECMO could be started. Sixty-eight infants (40.7%) were given ECMO therapy, and 11 died (16.1%). Nine mothers were referred because of fetal conditions that might require ECMO; of these infants, two died during delivery and three had contraindications to the use of ECMO. The four remaining infants were given ECMO therapy; three survived. The overall mortality rate was 27.5% (46/167); 18 (39.1%) of the 46 deaths were associated with transfer. The mortality rate associated with congenital diaphragmatic hernia was 63.6%. We recommend early transport of infants with this type of hernia during the postoperative "honeymoon" or during in utero transport with delivery at an ECMO center. We also recommend that infants with meconium aspiration syndrome be transported to an ECMO center when an oxygenation index of 25 is reached. The mortality rate associated with transport needs to be considered in evaluating ECMO programs. Earlier, expedited transfers may increase the survival rate.

The use of extracorporeal membrane oxygenation (ECMO) has increased significantly during the last 4 years, with more than 2400 infants now having been treated with the technique. In spite of an ill-defined role for ECMO as well as the potential for neurologic sequelae for these patients, additional centers continue to be established across the United States. To provide information regarding the number of babies who could be expected to require ECMO, the early neonatal deaths for the state of Georgia were reviewed for the 2-year period 1983-1984. By means of both linked birth and death certificate analysis and chart review of infants with a birth weight of 2500 g or more, identification was made of 36 infants whom we classified as potential ECMO candidates. These infants were thought to represent 80% of all infants who would have received ECMO during the 2 years, resulting in an estimate of 1 patient receiving ECMO per 3717 live births for the state. With a predicted survival rate of 80% for this group, the state neonatal mortality rate would have declined by 0.13 per 1000 live births, a decrease of 1.4%.

In the past 4 years at the Medical College of Georgia, a total of 74 patients underwent extracorporeal membrane oxygenation (ECMO) with 62 (84%) survivors. Forty-seven of these infants had meconium aspiration syndrome and 11 had diaphragmatic hernia. The use of ECMO, when indicated, after reduction and repair of the diaphragmatic hernia, results in normal oxygen delivery, allows time for pulmonary maturation, and increases survival. A total of 27 referrals for diaphragmatic hernia were studied. Six infants had surgical repair and did not require ECMO. Eleven patients, after surgical repair, were treated with ECMO and seven survived. More importantly 10 patients died before the use of ECMO. Six infants died either before or during transport from referring hospitals and four died while in the delivery room or neonatal unit before ECMO. Of these 10 infants, eight were potential candidates for ECMO. Thirteen of the twenty-seven (48%) infants survived. Seven of eleven (64%) infants who received the benefit of ECMO survived. Eight infants who met the criteria for ECMO died before its use. Had ECMO been used in those eight infants, our data suggests that at least four may have survived. The data from this report support the concept that infants undergoing surgical repair of diaphragmatic hernia, when ECMO is not available, should be referred to an ECMO center in the early postoperative period. Furthermore infants with prenatal diagnosis of diaphragmatic hernia should be delivered at a center where surgical as well as ECMO expertise are available.

The case of bilateral ovarian fibromas occurring in an 8-year-old black girl is reported. These lesions occur rarely in premenarchal females and may be a manifestation of Nevoid Basal Cell Syndrome. Calcifications are reported to occur rarely in ovarian fibromas but seem to occur frequently in fibromas in children. Management is guided by the benignity of the lesion and consists of surgical excision of the fibroma. Preservation of normal ovarian tissue is recommended with the acknowledged risk of recurrence of the fibroma.

Systemic hypertension has been associated with extracorporeal membrane oxygenation (ECMO) applied in neonatal respiratory failure. To determine the incidence of ECMO-related hypertension, we reviewed blood pressure measurements from indwelling aortic catheters in 31 infants consecutively placed on ECMO. Systemic hypertension (systolic blood pressures greater than 100 mm Hg for 4 or more consecutive hours) developed in 18 of the 31. Causes investigated included the roles of renin secretion, sodium, and colloid loads. There was no evidence of increased plasma renin activities in hypertensive infants (H), when compared with their own pre-ECMO controls or with the nonhypertensive infants (NH). Sodium and colloid loads and their rates of delivery were not different between H and NH. No consistent duration of ECMO was clearly associated with development of hypertension (mean time on ECMO at onset of hypertension, 43.8 +/- 38.5 hours; range, 1 to 142 hours). Demographic information was not statistically significant. Contrary to previous reports, H did not seem predisposed to an increased incidence of intracranial hemorrhage. Development of hypertension during ECMO is not related to increased plasma renin activity, sodium or colloid loads, or their rates of infusion.

From April 1985 to November 1987, over 100 infants were evaluated for extracorporeal membrane oxygenation (ECMO) in the treatment of respiratory failure. Of these infants, 40 underwent ECMO after failure of conventional treatment. Four developed gastroduodenal perforations. One developed a perforation prior to going on ECMO and died after several hours on ECMO, one developed a perforation while being treated conservatively for respiratory failure that never required ECMO, and two developed perforations requiring laparotomy while on ECMO. These two infants constitute the first report of successful gastrorrhaphy in infants while being supported by ECMO and anticoagulation with heparin. Particular measures helpful in the management of these infants included near-total cardiopulmonary bypass, reduction of the activated clotting time to 170 to 200, transverse abdominal incision for exposure, use of electrocautery, appropriate drainage of the operative site, insertion of a gastrostomy for gastric decompression and irrigation, rapid weaning from ECMO as soon as respiratory support could be provided by conventional methods, and the use of massive blood and platelet transfusions. In summary, 33 of 40 infants undergoing ECMO survived. Furthermore, two of the three infants with intestinal perforation who underwent ECMO have survived without significant short-term sequelae, and are 24 and 30 months of age, respectively. Therefore, we believe that despite severe respiratory failure requiring ECMO and anticoagulation with heparin, infants with intestinal perforation can be managed surgically with anticipated survival and good long-term prognosis.

To determine the presence and extent of thrombus formation in the apparatus used for extracorporeal membrane oxygenation we studied various portions of the polyvinylchloride circuit from five infants who received extracorporeal membrane oxygenation for 70 to 330 hours. All infants had right-sided cannulation. Sections were cut from the circuit at the time of decannulation and subjected to light and scanning electron microscopy. The site that contained the most thrombus formation was the membrane oxygenator bypass circuit, which is subjected to repeated periods of unclamping and clamping to direct blood flow through the membrane oxygenator. Autopsy results from nonsurvivors showed evidence of pulmonary and renal infarcts, a left frontal lobe infarct, a thromboembolus of the left external and internal carotid arteries, and thrombi in the lungs, kidney, brain, and coronary arteries. One survivor had computed tomographic evidence of infarction of the left middle cerebral artery distribution. We suggest that the areas of the extracorporeal membrane oxygenation circuit subjected to repeated changes in flow dynamics may be the source of microemboli.

A case of neonatal teratoma of the nasopharynx associated with polyhydramnios and respiratory distress is presented. Surgical excision was carried out after preoperative evaluation with high resolution CT. Computed tomography is valuable in distinguishing a teratomatous tumor and in searching for intracranial extension and malignant characteristics.

Vascular access in the pediatric patient with endstage renal disease (ESRD) can be a surgical challenge to perform as well as maintain. We have recently developed a new technique of elevating the basilic vein in the upper arm for the arteriovenous (AV) fistula instead of using a polytetrafluoroethylene (PTFE) graft. During the past 2 years, 66 patients with ESRD and unsuitable superficial veins have had basilic vein elevation. Of these 66 patients, four have been in children, aged 11 to 19 years. The technique of mobilization of the vein from the elbow to the axilla was similar to that described by Dagher et al except that we used one long incision. The new feature of this technique is that the vein is not rerouted laterally through a subdermal tunnel. Instead, after the AV fistula to the side of the brachial artery is created, the vein is elevated within the incision by closing the subcutaneous fascia beneath, and the skin over, the vein. Most veins could be used in 2 to 4 weeks. Of the entire group, the patency rate has been 55 of 66 (83.3%), with no infections or long-term morbidity. Of the four pediatric patients, there have been no thromboses or infections. We believe the operation to be easier to perform than the standard PTFE bridge graft. The subsequent AV fistula is easy to access, less likely to cause a "steal syndrome," less likely to become infected, and if it does become infected, more likely to respond to treatment with antibiotics.

Mesoblastic nephroma is a distinctive pathologic renal tumor with unique clinical, therapeutic, and prognostic patterns. This report reviews 51 patients (2.8% of 1905 patients submitted to NWTS with renal tumors) with this diagnosis from the NWTS contrasting this disease entity with Wilms' tumor. There were 33 males and 18 females, predominantly term babies born after uncomplicated pregnancies. The mean age at tumor excision was 3.44 +/- 0.6 mo (one child 9 yr). A palpable mass was the predominant presentation in 48 patients and in addition hematuria (9), hypertension (2), vomiting (3), and jaundice (1) were noteworthy. Diagnostic studies included IVP (49 positive, 2 negative) and ultrasound (15 positive, 1 negative). Adequate operative excision was achieved in 43 of 51 patients while 8 children had local extension and 10 had tumor spillage. Operation alone (23), predominantly since 1978, surgery plus chemotherapy (24), prior to 1978, and surgery, chemotherapy, and radiation therapy (4), prior to 1976, were the modes of therapy. The follow-up ranges from 4 mo to 11.5 yr. Survival was excellent; 50 patients survive (98%), only 1 dying of sepsis. These data suggest that mesoblastic nephroma contrasts with Wilms' tumor in that it occurs in a younger age group, has a benign biologic behavior, and a more favorable outcome. Aggressive multimodal treatment though utilized in the early years of the study is not essential to achieve this outcome.

A ventriculoperitoneal shunt for infants has been successfully adapted to function in a reversed manner by sending ascitic fluid back into the circulation of the premature infant. This technique permits successful peritoneovenous shunting in the smallest infant.

Farm-related trauma occurs in more than 25,000 children per year with almost 300 patients dying from these preventable injuries. The incidence of associated farm-machinery injuries and fatalities is increasing at an alarming rate with the majority occurring in young boys during the summer months. Between 1979-1985, 234 patients with traumatic injuries were admitted to our Pediatric Surgery Service. Seven of these, six boys and one girl, age ranges from 2-15 years were treated for severe farm-related injuries. Modified injury severity score was calculated with an average score of 31.5 (range 9-66). Four patients sustained or required amputation of a major extremity(ies) as a result of the injury. Two patients had multiple long bone fractures with associated neurologic or abdominal injury. One patient exsanguinated from massive liver lacerations. Five of the six surviving patients are disabled to varying degrees because of their injuries. This report provides support for the establishment of federal safety standards for farm-related equipment. Guidelines for prevention are outlined. We believe that the child physician is obliged to encourage education programs in farming communities on safety measures and further should endorse the application for farms.

The pathogenesis and optimal treatment of choledochal cyst have long remained questions of considerable speculation and dispute. Because the pregnancy of a 37-year-old woman was felt to be at risk, five antenatal ultrasound examinations were made. The fourth examination at 31.5 weeks of gestation demonstrated a choledochal cyst. Following birth, the child was studied with repeat ultrasound examinations and scintigraphy. The results of these studies plus the findings at surgery contributed new evidence regarding the possible pathogenesis and optimal treatment of choledochal cysts. Although the time at which the cyst originated is compatible with the concept of reflux of pancreatic juice into the common duct, no abnormal junction of the pancreatic and common duct was identified. No evidence of obstruction as part of the pathogenesis could be demonstrated. Progressive changes in the choledochal cyst in the first ten days of life suggested that delay in diagnosis and treatment of a choledochal cyst may contribute to early complications such as cholangitis. Early excision of the cyst in the newborn is considered to be the optimal treatment and may pose less risk to the patient than delayed surgical exploration.

Transanal suction injuries were sustained in 1981 by five children when they sat upon uncovered swimming area drain sites. Tears of the rectosigmoid areas occurred in each with associated evisceration and loss of substantial amounts of small intestine because of mesenteric separation. These cases are reviewed.

We report a 7-year-old male with ampicillin-induced Stevens-Johnson syndrome with subsequent extensive skin, conjunctival, oropharyngeal, and laryngeal involvement. Over the next 5 months, he developed complete blindness and dysphagia. A barium swallow revealed absence of both right and left pyriform sinus, and a stricture involving the entire esophagus. Retrograde dilatations, complicated by malignant hyperthermia, have subsequently allowed for the difficult progression from an eight to a 40 French bougie. Eighteen months since the diagnosis of esophageal stricture, he has a normal appearing esophagus and is swallowing without difficulty.

The effect of right common carotid artery ligation required for arteriovenous extracorporeal membrane oxygenation (ECMO) was investigated in 35 infants. Their neonatal course was reviewed for evidence of right-sided ischemia of the brain, as suggested by the presence of focal seizures, hemiparesis, focal abnormalities on electroencephalography, or infarct or hemorrhage demonstrable on neuroimaging studies. A significant incidence of left focal seizures (9/35) versus right focal seizures (2/35) was noted, suggesting an effect of the carotid ligation on right hemisphere function. Computed tomographic scans (20/35 infants), electroencephalograms (18/35), ultrasound scans (31/35), and neurologic examinations did not reveal an increased incidence of right hemisphere abnormalities. These data suggest that systematic evaluation of the effects of right common carotid ligation should proceed as discussion continues on expanding the use of ECMO.

Primary esophagoesophagostomy is the treatment of choice for repair of esophageal atresia, particularly the more common type C atresia. Debate continues, however, regarding repair of the type A, or long-gap esophageal atresia. Since the pioneering work of Livaditis, Howard and Myers, the frequency of primary repair of long-gap atresia has increased. Interposition grafting, however, remains as the treatment for gaps longer than 6 cm or with absence of a distal intrathoracic esophageal segment. We report a case of primary esophagoesophagostomy with proximal esophagomyotomy in a 1,900-g infant with an absent distal intrathoracic esophageal segment and an eight vertebral body gap. Utilizing daily bougienage of the proximal and eventually the distal segment, a 1-cm gap was present at 6 months of age. With intraoperative fluoroscopy, the distal intra-abdominal esophageal segment was manipulated thru the esophageal hiatus. Thru an extrapleural approach with a proximal esophagomyotomy, a delayed primary anastomosis was successfully performed. She is currently 3 years old and has a normal barium swallow without stricture or gastroesophageal reflux.

A patient with near-fatal blunt trauma to the liver was subsequently found to have complete disruption of the left hepatic and common ducts. Establishment of biliary-enteric drainage by means of Roux-en-Y jejunal limb required the use of a specially designed Silastic transhepatic stent. This stent provided direct contact between the jejunal mucosal graft and the recessed left hepatic duct. Guidelines for biliary tract reconstruction are discussed.