Intracellular cytokine production by fetal and adult monocytes

BACKGROUND/PURPOSE

In light of the neonate's increased susceptibility to systemic infection, the authors hypothesized that adult and fetal monocytes have different cytokine expression profiles in response to lipopolysaccharide (LPS), and interleukin (IL)-11, a counter-inflammatory cytokine.

METHODS

Samples of cord blood (n = 30) and adult blood (n = 30) were obtained and treated as follows: control (baseline expression), LPS exposure, and IL-11 or IL-11+LPS exposure. After incubation with a protein transport inhibitor, mononuclear cells were stained for intracellular tumor necrosis factor (TNF)-alpha, IL-1beta, IL-6, and IL-8. Each sample was then analyzed by flow cytometry for cytokine expression. Cytokine production was measured by the percent positive as well as the fluorescence index for each cytokine. Analysis of variance (ANOVA) and Students t tests were used for statistical analysis.

RESULTS

Baseline levels of IL-8 were significantly higher for fetal monocytes (P <.0001). After LPS exposure, fetal monocytes produced less TNF-alpha (P =.0105) and more IL-8 (P <.0007) relative to adult cells. IL-11 treatment reduced baseline production of IL-8 in fetal and adult monocytes (P <.05).

CONCLUSIONS

These results suggest that neonatal monocytes portray a different cytokine expression profile compared with adult monocytes. IL-11 treatment appears to alter the IL-8 expression of resting fetal and adult monocytes.

A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum

BACKGROUND/PURPOSE

The most common complication of the minimally invasive technique for repair of pectus excavatum (MIRPE) is bar displacement, which has been reported to occur in 9.5% of all cases, particularly in teenaged patients. The use of a lateral stabilizing bar has improved stability but has not eliminated the occurrence of this problem. The authors report a new technique added to the standard MIRPE that creates an additional third point of fixation of the pectus bar to prevent displacement.

METHODS

The technique requires the simple placement, via a spinal needle, of a nonabsorbable suture next to the sternum, encircling a rib and the bar, using a single 3-mm stab wound and thoracoscopic guidance. The suture simply is buried under the skin. Since 1998, this technique has been applied to 20 patients who underwent MIRPE.

RESULTS

The average age was 14 years; 80% were boys. Average operating time was 75 minutes, and all patients had thoracoscopy with the MIRPE. A lateral stabilizing bar also was used in 14 patients. Four patients had 2 struts placed. Average length of stay was 5.5 days. There were no early complications. Mean follow-up was 12 months. Bar displacement occurred in 1 patient early in the series in which an absorbable suture was used for fixation. One patient had a prolonged hospital stay of 7 days because of postoperative pain.

CONCLUSIONS

This modification to the original technique of MIRPE creates a 3-point fixation system that minimizes the risk of bar shifting even in teenaged patients. It does not add any significant time or cost to the operation, and it is fairly simple to perform. The authors believe that this technique decreases the occurrence of bar displacement, and they recommend its use for all patients with pectus excavatum considered candidates for the Nuss repair.

Effectiveness of beta-glucan collagen for treatment of partial-thickness burns in children

BACKGROUND/PURPOSE

Beta glucan collagen matrix (BGC), which combines the carbohydrate beta-glucan with collagen, has been used as a temporary coverage for adult partial thickness burns with reported good results. Observed advantages of BGC coverage include reduction of pain, improved healing, and better scar appearance. Potentially even more important in children is the elimination of painful daily dressing changes to the burned epithelial surface, as well as decreased fluid loss. This report details the authors' 2-year experience with BGC in a pediatric burn center.

METHODS

Retrospective chart review of 225 consecutive pediatric patients treated at our institution between 1997 and 1999 identified 43 patients (19%) with suspected partial thickness burns treated with BGC as the primary wound dressing. BGC was applied to a debrided burn wound and secured with steri-strips, kerlix, and an ace wrap. After 24 hours, adherence of the BGC was confirmed and then left open to air.

RESULTS

The most common cause of burn injury was scald (61%), followed by flame (37%), and contact (2%). The average age of patients was 5.5 years (range, 6 weeks to 16 years) and mean percent total body surface area burned was 9.3% (1% to 35%). Thirty-four patients (79%) had the BGC remain intact while the wound healed underneath, with excellent cosmetic results, minimal analgesic requirements, and no need for repetitive dressing changes. Nine patients (21%) had the BGC removed before wound healing: 6 patients lost the BGC because of progression of the burn to full thickness, 2 had BGC nonadherence over a joint, and 1 had an unexplained nonadherence.

CONCLUSIONS

Partial-thickness burns in children can be effectively treated with BGC with good results, even in infants and toddlers. BGC markedly simplifies wound care for the patient and family and seems to significantly decrease postinjury pain.

Pediatric laparoscopic splenectomy

BACKGROUND

Lateral laparoscopic splenectomy in adults, first reported in 1991, was begun with children in 1993.

METHODS

The authors reviewed records of 59 patients 2 to 17 years old who underwent laparoscopic splenectomy by the lateral approach between 1994 and 1998 at four medical centers. Patients received prophylactic penicillin or vaccinations preoperatively.

RESULTS

Of the 59 patients, 51 required splenectomy for one of the following conditions: idiopathic thrombocytopenic purpura, hereditary spherocytosis, or sickle-cell disease. Splenomegaly was found in 86% of the patients, and ten accessory spleens were resected. No deaths or infection occurred, and only three patients had perioperative complications: acute chest crisis, small diaphragmatic injury, and intraoperative hemorrhage. One operation was converted to a minilaparatomy because of difficulty with specimen extraction.

CONCLUSIONS

Pediatric laparoscopic splenectomy is safe and effective, resulting in little blood loss, rapid recovery, and a good cosmetic outcome.

Necrotizing enterocolitis in infants with very low birth weight

Necrotizing enterocolitis (NEC) is a disease in which the primary risk factor is prematurity. Despite, and partially as a result of, the tremendous strides neonatal care has taken, it is a major cause of morbidity and mortality of the newborn. The infant with very low birth weight is particularly susceptible, and the management of the condition in this group differs somewhat from other neonates. The outcomes continue to improve, but there are significant sequelae. Prevention, which would be the best "cure," is elusive, in no small part because of the multifactorial nature of the etiology of NEC.

Minimally invasive pectus surgery

The technique of minimally invasive repair of pectus excavatum is a new operation that allows for repair of this deformity without any cartilage resection or sternal osteotomy. The procedure has revolutionized the management of pectus excavatum. The innovative incorporation of thoracoscopic techniques and small but important modifications to the technique have made this operation very effective and safe.

Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases

BACKGROUND/PURPOSE

Since the first report in 1997 by Dr Nuss of the technique for minimally invasive repair of pectus excavatum (MIRPE), the popularity and demand for this operation has increased dramatically. Many pediatric surgeons became familiarized with MIRPE and have applied it to a large number of patients. Outcomes and complications have not yet been defined.

METHODS

A comprehensive survey of APSA members was conducted to review technical problems, complications, and outcomes of this new technique.

RESULTS

Of the 74 survey responders, 31 (42%) currently use the MIRPE as their procedure of choice, and 251 cases were reviewed. A total of 74.2% of surgeons relied on direct observation and written documentation to obtain training in MIRPE. Less than 60% used the chest index in the preoperative assessment. A total of 98% used the Walter Lorenz bar for the MIRPE. The most common complication was bar displacement or rotation requiring reoperation (9.2%). Pneumothorax requiring tube thoracostomy was reported in 4.8%. Less common problems included infectious complications (2%), pleural effusion (2%), thoracic outlet obstruction (0.8%), cardiac injury (0.4%), sternal erosion (0.4%), pericarditis (0.4%), and anterior thoracic artery pseudoaneurysm (0.4%). Three patients (1.2%) required early strut removal. Reoperation using the open modified Ravitch approach was performed in 2 patients (0.8%). Most surgeons indicated that teenaged patients (>15 years old) were at higher risk for complications. Thoracoscopy in combination with MIRPE was used by 61% of the surgeons. Overall patient satisfaction was rated as excellent or good (96.5%).

CONCLUSIONS

The relatively high incidence of problems with MIRPE is probably related to the learning curve associated with the introduction of this new technique. Awareness of technical details, careful patient selection, use of a stabilizing bar, and thoracoscopy likely will result in decreased complications. Long-term results are yet to be determined. The development of a national registry is of great importance for further outcome analysis of MIRPE.

A new method of treatment for complete tracheal rings in an infant: endoscopic laser division and balloon dilation

PURPOSE

The authors describe a new technique for management of complete tracheal rings in infants.

METHODS

The procedure consists of rigid bronchoscopy with KTP laser division, in the posterior midline, of the complete rings and gradual advancement of the bronchoscope aided by endoscopic balloon dilation.

CONCLUSIONS

The laser division, coupled with balloon dilation, allows for controlled separation of the cartilages posteriorly. The anterior esophageal wall buttresses the posterior tracheal separation.

Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard

OBJECTIVE

To describe the surgical technique and early clinical results after a one-stage laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease.

SUMMARY BACKGROUND DATA

Recent trends in surgery for Hirschsprung's disease have been toward earlier repair and fewer surgical stages. A one-stage pull-through for Hirschsprung's disease avoids the additional anesthesia, surgery, and complications of a colostomy. A laparoscopic-assisted approach diminishes surgical trauma to the peritoneal cavity.

METHODS

The technique uses four small abdominal ports. The transition zone is initially identified by seromuscular biopsies obtained laparoscopically. A colon pedicle preserving the marginal artery is fashioned endoscopically. The rectal mobilization is performed transanally using an endorectal sleeve technique. The anastomosis is performed transanally 1 cm above the dentate line. This report discusses the outcome of primary laparoscopic pull-through in 80 patients performed at six pediatric surgery centers over the past 5 years.

RESULTS

The age at surgery ranged from 3 days to 96 months. The average length of the surgical procedure was 2.5 hours. Almost all of the patients passed stool and flatus within 24 hours of surgery. The average time for discharge after surgery was 3.7 days. All 80 patients are currently alive and well. Most of the children are too young to evaluate for fecal continence, but 18 of the older children have been reported to be continent.

CONCLUSION

Laparoscopic-assisted colon pull-through appears to reduce perioperative complications and postoperative recovery time dramatically. The technique is quickly learned and has been performed in multiple centers with consistently good results.

Detection of intracellular tumor necrosis factor alpha in stimulated fetal cells

BACKGROUND

It is unknown if immature fetal cells produce tumor necrosis factor (TNF) alpha in the same manner that adult cells do. The aim of this study was to determine the feasibility of early detection of intracellular TNF produced by circulating human monocytes (Mo) and lymphocytes (Ly) using flow cytometry and to compare the stimulation profiles of mature and fetal cells.

MATERIAL AND METHODS

Fetal umbilical cord blood (n = 10) and adult volunteer blood (n = 10) were obtained. In vitro stimulation with endotoxin (LPS) and ionomycin-PMA was performed. Brefeldin A was added to prevent extracellular transport of TNF. Cell type was determined by using CD-14 marker separating monocyte and lymphocyte populations. Anti-human TNF monoclonal antibody was used to detect intracellular TNF by flow cytometry analysis.

RESULTS

Thirty to sixty thousand cells were analyzed per sample. Average TNF expression of stimulated fetal Mo was 28.2%, and that of fetal Ly was only 1.1%. Adult stimulated Ly had an average TNF expression of 31.9%, and adult Mo, 29.6% (P < 0.05 for adult Ly vs fetal Ly).

CONCLUSION

TNF flow cytometry analysis allows assessment of individual cell types and their ability to produce that cytokine. Fetal cells are able to produce TNF when stimulated, but the stimulation profile of Ly differs from that of adult samples. This observation may be of clinical importance in evaluating the response of immature cells to a septic stimulus. Flow cytometry is reliable, reproducible, quick, and easily obtained from a small sample of peripheral blood. Clinical use will be applicable once appropriate controls are developed, as reported in this study.

"One-stop" surgery: implications for anesthesiologists of an expedited pediatric surgical process

BACKGROUND

"One-stop surgery" (OSS) allows pediatric patients to undergo initial surgical evaluation, anesthesia, surgery, and discharge home, on the same day.

METHODS

Patients referred for umbilical hernia repair, circumcision, or central venous catheter removal completed a screening questionnaire, after which they were scheduled for initial surgical and anesthesia evaluation if eligible and had surgery if indicated on the same day.

RESULTS

Three patients had comorbidity precluding OSS, two patients refused indicated surgery, two patients did not require surgery, and 12 patients did not keep their appointment. Eighty patients had surgery without complications. Average total time was significantly shorter for OSS than non-OSS for circumcision (120 vs 142 min) and umbilical hernia repair (139 vs 165 min) but similar for catheter removal (100 vs 109 min). All families were satisfied with OSS.

CONCLUSIONS

One-stop surgery appears to be a safe, efficient, and convenient alternative to the traditional process for patients and their families.

One-stop surgery: evolving approach to pediatric outpatient surgery

PURPOSE

Maximizing patient satisfaction is of prime importance in today's competitive outpatient surgery market. The authors recently devised a system, one-stop surgery, which simplifies outpatient surgery for pediatric patients and their families by combining the traditionally separate preoperative evaluation and subsequent operation into one visit. This report describes our initial experience with one-stop surgery.

METHODS

Umbilical hernia repair, circumcision, and portacath removal were considered surgical procedures appropriate for our one-stop surgery pilot study. Medical information obtained by phone or fax from referring physicians was used to identify potential candidates. Families were contacted, precertified for their surgical procedure, and given nothing by mouth instructions. The day of surgery the child was evaluated by the attending pediatric surgeon. If the diagnosis was confirmed, and no contraindications to surgery were identified, the child immediately underwent the prescheduled surgical procedure.

RESULTS

From April through October 1997, 61 children were scheduled for one-stop surgery. Nine patients (15%) were no shows, and one additional family opted not to proceed with circumcision. The remaining 51 children (83%) underwent their one-stop surgical procedure: umbilical hernia repair (n = 23), circumcision (n = 19), portacath removal (n = 8), and inguinal hernia repair (n = 1). No child had an anesthetic contraindication to surgery, and only one minor postoperative complication (wound hematoma) occurred.

CONCLUSIONS

This pilot study has demonstrated that with appropriate patient screening and cooperation of the entire surgical team, a variety of outpatient surgical procedures can be handled using this one-stop surgery method. By combining one-stop surgery with our previously reported phone follow-up system, many minor surgical procedures can be managed with only one visit to the hospital. Decreasing the "hassle factor" of outpatient surgery for children and their families, who frequently live far from their closest children's hospital, while providing the highest quality of specialized surgical and anesthetic care, may potentially be a very powerful marketing tool for pediatric surgical specialists.

Impact of segmental grafts on pediatric liver transplantation--a review of the United Network for Organ Sharing Scientific Registry data (1990-1996)

PURPOSE

The aim of this study was to assess the relative impact of segmental grafts from cadaveric and living donors on outcomes in 3,409 pediatric transplants (<18 years) between 1990 and 1996.

METHODS

Analysis of the United Network for Organ Sharing (UNOS) Scientific registry data from 1990 to 1996 was performed.

RESULTS

Liver grafts consisted of 2,636 whole grafts (WLG), 246 liver donor grafts (LDG), 89 split liver graft (SLG), and 438 reduced-size grafts (RSG). Although the number of pediatric transplants were unchanged between 1990 and 1996, segmental grafts made up an increasing proportion from 14.5% to 29.2%, and WLG decreased proportionately. The increase among segmental grafts occurred for LDG (threefold), followed by SLG (53%) and RSG (50%). One-year graft and patient survival rates for 3,409 transplants were 69.7% and 81.9%, respectively and were significantly higher (P<.001) in nonhospitalized patients than in hospitalized patients (79.8% and 91.3% v 61.0% and 73.7%). LDG graft survival (75.9%) was comparable with WLG(70.9%) but significantly better at 1 year than SLG (60.3%, P = .007) and RSG (61.1%, P = .001), even after excluding retransplants and ICU patients. Patient survival rates were not different statistically between groups. A separate analysis of outcomes in recipients less than 1 year of age suggested significantly better graft and patient survivals for LDG (83.3% and 89.4%) than for WLG (62.3% and 76.5%) and RSG (62.7% and 75%).

CONCLUSIONS

Segmental liver grafts from cadaveric and living donors constitute an increasing proportion of pediatric transplants. Survival rates of cadaveric segmental graft are inferior to those of live donor segmental grafts even after adjustment for medical condition. Live donor grafts demonstrate consistently superior graft and patient outcomes in pediatric recipients less than 1 year of age, and should be promoted aggressively as a solution to the critical shortage of size matched grafts in small recipients.

Acute chest syndrome in the postoperative sickle cell patient

BACKGROUND/PURPOSE

Acute chest syndrome (ACS), a phenomenon of pulmonary sequestration in sickle cell disease (SCD) patients, is frequently missed in the postoperative SCD child. The constellation of symptoms range from fever and respiratory distress to abdominal discomfort. In its most fulminate state, the syndrome has been reported in some series to carry almost a 25% to 50% mortality rate in the postoperative patient. The incidence in pediatric patients in the era of minimally invasive surgery is unknown.

METHODS

Since December 1995, 63 episodes of ACS have been documented in the nearly 500 SCD children seen at our institution. Six of 63 episodes occurred within 2 weeks after a surgical procedure under general anesthesia. During this period, 59 operations were performed by the pediatric surgery service on SCD patients with an ACS incidence of 10.2%. Careful review of the preoperative, intraoperative, and postoperative management of these patients was performed.

RESULTS

All six received preoperative oxygen saturation monitoring and intravenous fluid (IVF) hydration. One half of these patients required transfusion to achieve a hemoglobin level of greater than 10 mg/dL. Documentation of intraoperative temperature, hypoxia, volume status, and hypercarbia as well as any atypical perioperative events were monitored and reviewed. All patients received postoperative oxygen supplementation and IVF hydration. Onset of ACS ranged from 1 hour to 7 days postoperatively. Only one of six was thought to be of microbial etiology (elevated mycoplasma titers), and all patients received prophylactic antibiotic and aggressive pulmonary therapy. Overall length of hospitalization was increased with an average stay of 6.1 days. There were no postsurgical ACS deaths.

CONCLUSIONS

Despite close attention and avoidance of known risk factors for development of postoperative SCD complications, ACS occurred with an incidence much higher than previously reported in the literature (0.4% v 10.2%). Interestingly, five of six cases were after laparoscopic procedures suggesting that the advantages of laparoscopy, such as reduced postoperative pain, do not extrapolate to decreased incidence of ACS.

Persistent pulmonary hypertension in a neonate with cystic adenomatoid malformation of the lung following lobectomy: survival with prolonged extracorporeal membrane oxygenation therapy

A full-term neonate is reported with congenital cystic adenomatoid malformation of the lung treated by lobectomy with development of pulmonary hypertension. The infant was successfully treated with extracorporeal membrane oxygenation (ECMO) for persistent pulmonary hypertension, which developed postoperatively. An 18-day course of venovenous ECMO was necessary to effectively reverse the severe pulmonary hypertension. This was probably a result of significant pulmonary hypoplasia of the compressed lung. Although not all congenital cystic adenomatoid malformations of the lung are associated with pulmonary hypoplasia and persistent pulmonary hypertension, this is one case where severe pulmonary hypertension developed secondary to a mass effect by a large lesion in the chest.

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.

Pediatric laparoscopic biliary tract surgery

Laparoscopic cholecystectomy is being performed with increasing frequency in children. The authors discuss the presentation, surgical technique, overall results, and potential complications associated with pediatric laparoscopic biliary tract surgery, citing a large personal experience as well as that reported in the literature.

Enteric defensin expression in necrotizing enterocolitis

Immaturity of local innate defenses has been suggested as a factor involved in the pathophysiology of necrotizing enterocolitis (NEC). The mRNA of enteric human defensins 5 (HD5) and 6 (HD6), antibiotic peptides expressed in Paneth cells of the small intestine, have significantly lower levels of expression in fetal life compared with the term newborn and adult. In the current study, intracellular HD5 was demonstrated by immunohistochemistry at 24 wk of gestation, but at low levels, consistent with findings at the mRNA level. These data suggest that the low level enteric defensin expression, characteristic of normal intestinal development, may contribute to the immaturity of local defense, which predisposes the premature infant to NEC. To test if levels of defensin expression are altered in NEC, specimens from six cases of patients with NEC and five control subjects (four patients with atresia and one with meconium ileus) were analyzed to determine HD5 and HD6 mRNA levels by in situ hybridization. Compared with the control group, the level of enteric defensin expression per Paneth cell assessed by image analysis was increased 3-fold in cases of NEC (p = 0.02, analysis of variance and covariance). In addition, the number of Paneth cells was increased 2-fold in the small intestinal crypts of NEC specimens compared with those of control subjects (p < 0.01, covariance analysis). In healthy tissue, peptide levels within Paneth cells paralleled mRNA levels through development. In tissue from infants with NEC, the steady state level of intracellular peptide was not increased in conjunction with the observed rise in defensin mRNA. A straightforward interpretation of this finding is that HD5 is actively secreted in this setting and the Paneth cells maintain a constant steady state level of intracellular peptide, but the possibility of translational regulation of peptide expression is also consistent with these data. The associations between NEC and enteric defensin expression reported here offer support for future studies to address the role of these endogenous host defense factors in the pathophysiology of this disease.

Wandering spleen: a challenging diagnosis

Wandering spleen is rare, particularly in children, and diagnosis is difficult. It usually occurs at 20 to 40 years of age, and most cases are seen in women. Diagnosis is difficult because of lack of symptoms, unless splenic torsion has occurred. Patients usually have an asymptomatic abdominal mass, an acute abdomen, or, most commonly, a mass associated with pain. Laboratory data are nonspecific, but the diagnosis can be confirmed by imaging studies; computed tomography and duplex ultrasonography are preferred modalities. Treatment is operative because of complications of splenic infarction and possible splenectomy. Splenopexy is the treatment of choice for a noninfarcted wandering spleen. Splenectomy should be done only when there is no evidence of splenic blood flow after detorsion of the spleen. We review our experience with wandering spleen in two pediatric patients, one treated with splenopexy and the other with splenectomy.

Neonatal sternal cleft associated with an extrathoracic cystic mass

This report describes an unusual case of cystic exophytic tumor associated with a complete sternal cleft. The tumor masked the presence of sternal cleft on prenatal ultrasound scan.

Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders

A multidisciplinary approach using traditional open surgery, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery has revolutionized the care of the adult with pancreaticobiliary disease. This study focuses on a similar collaborative effort to diagnose and treat children with pancreaticobiliary disorders. Charts of all patients treated on the pediatric surgery service between June 1990 and May 1995, who also underwent ERCP, were abstracted for disease process, presenting symptoms, laboratory evaluation, surgical or endoscopic procedures, and eventual outcome. Twenty-six children were identified, ranging from 6 months to 19 years of age. Pancreaticobiliary disorders included pancreas divisum (n = 1), choledochal cyst (n = 4), pancreaticobiliary trauma (n = 4), cholelithiasis and choledocholithiasis (n = 17). The pancreaticobiliary tree was successfully visualized by ERCP in 25 of 26 (96%) patients. Fifteen of these patients also underwent attempted therapeutic endoscopic procedures, with 13 (87%) performed successfully. Three patients with choledochal cyst had stents placed preoperatively for cholangitis, all of whom have undergone successful choledochal cyst excision. Two trauma patients underwent attempted stenting of a bile leak and bile duct stricture, respectively, both of which were unsuccessful, necessitating surgical correction. Seventeen patients with cholelithiasis underwent ERCP to rule out choledocholithiasis. Ten patients were found to have common duct stones, and all stones were endoscopically extracted, including those in a 6-month-old child. Overall survival rate was 96% (25 of 26), with the one death occurring in a trauma patient unrelated to his pancreaticobiliary disorder. A multidisciplinary approach using traditional open surgery, ERCP and laparoscopic surgery can successfully treat even young children with pancreaticobiliary disorders. In experienced hands, diagnostic ERCP and therapeutic endoscopic intervention can be performed successfully in most pediatric patients, greatly simplifying the surgical management of these potentially complex problems.

Esophageal replacement using the colon: is it a good choice?

Thirty-eight children (2 months to 26 years of age) underwent esophageal replacement at our institution between 1962 and 1993. Twenty-four patients had esophageal atresia, with the replacement performed at a mean age of 17 months. The remaining patients (37%) had strictures and were older (mean, 7.4 years). Replacement procedures involved the right colon in 61% of cases and the transverse left colon in the others (39%). Sixty-three percent were placed substernally and 37% were done in transthoracic fashion. The average length of stay in the hospital was 34 days (range, 11 to 256 days.) Early complications (within 30 days) included cervical anastomotic leaks (11 patients; 29%) pneumonia (4), would infection (2), pneumothorax/hemothorax (3), wound dehiscence (1), prolonged ventilation (2), vocal cord paralysis (1), Horner's syndrome (1), pancreatitis (1), and perforated graft (1). Despite the incidence of early leaks, only two persisted long-term (more than 3 months). Other late complications included significant proximal strictures (5), and cologastric strictures developed in five patients. Seven cases were considered graft failures (18%), and all of these eventually require graft replacement. Additional problems included redundant graft requiring revision (4) and dumping syndrome (2). There were six cases of intestinal obstruction caused by adhesions. Four of these involved intrathoracic obstruction of the graft and two involved small bowel obstruction. There was only one death, which occurred late and was not related to the primary disease or procedure. Long-term follow-up data were available for 20 patients (53%). The follow-up period ranged from 1 to 33 years (mean, 12 years). Fourteen had excellent results after the initial interposition, being able to eat and function well without any further intervention. Seven patients (18%) have had poor results and 17 (45%) required additional procedures to obtain good functional results. In our experience, the colon continues to be a good option for esophageal replacement, but additional procedures frequently are necessary to optimize the functional outcome. Good results can be expected in the majority of cases, but late problems (ie, redundant colon and poor emptying) are not unusual, and careful follow-up is essential in the management of such patients.

Endodermal sinus tumor in children

Malignant germ cell tumors account for about 3% of neoplasms in children, and endodermal sinus tumor (EST) is the most common histological subtype. The authors reviewed 22 years' experience (at their institution) in the management of 37 patients with this tumor. Fifteen of them (41%) had a sacrococcygeal primary, 10 had a testicular tumor (27%), 6 had an ovarian tumor (16%), 3 had a vaginal tumor (8%) and 3 had tumors at other sites (8%). Seven (19%) patients presented with metastatic disease, primarily pulmonary. The serum alpha-fetoprotein (AFP) level was elevated in all cases tested. The initial chemotherapy regimen included vincristine, actinomycin, cyclophosphamide (VAC), and Adriamycin (6 patients), but since 1985 the regimen has been changed to include cisplatin or Carboplatin, etoposide, and bleomycin (21 patients). Eight patients with testicular tumors initially were treated with surgical excision alone. Computed tomography results were a poor predictor of recurrence, but AFP surveillance was extremely sensitive. No second-look operation detected residual tumor in the absence of AFP elevation. Initial relapse for all patients tended to occur early (within 2 years), locally, and often with pulmonary metastases. Although historically the prognosis for patients with EST has been poor, the overall 2-year survival rate in this series was 70%. The best prognosis was among the children who had a testicular primary tumor (survival rate, 100%). The 2-year survival rate for patients with ovarian tumors was 67%; for those with sacrococcygeal primaries it was 60%. These results suggest that the prognosis for children with EST has improved significantly over the past decade. Contributing factors include therapy based on cisplatin, etoposide, and bleomycin, and relapse surveillance with serial AFP determinations. Second-look procedures should be reserved for patients who have an increasing level of serum AFP, suspicious computed tomography findings, and no obvious evidence of metastatic disease.

Orthotopic liver transplantation for inflammatory myofibroblastic tumor of the liver hilum

Inflammatory myofibroblastic tumor is a rare gastrointestinal neoplasm. The authors report the case of a 5-year-old girl who initially presented with gastric outlet obstruction secondary to an inflammatory myofibroblastic tumor along the lesser gastric curvature. A subtotal gastrectomy and wedge resection of a left hepatic lobe nodule were performed. Obstructive jaundice developed one month postoperatively. Computerized tomography, percutaneous transhepatic cholangiography, and selective celiac and mesenteric arteriography showed a mass that involved the left hepatic lobe, with concomitant high-grade biliary obstruction and portal venous encasement. Percutaneous biliary drainage was performed. During laparotomy, the tumor was found to be unresectable, and the patient was referred to the Liver Transplant Service at The Children's Hospital of Philadelphia. A total hepatectomy with temporary portocaval shunt was performed, leaving the inferior vena cava in situ. At the back table, an ex vivo left trisegmentectomy was performed, followed by reimplantation of the posterior segment of the right hepatic lobe. The reimplanted liver segment functioned poorly, and completion hepatectomy with portocaval shunt was performed 24 hours postoperatively, because of severe coagulopathy, intraabdominal bleeding, and hemodynamic instability. The patient's condition stabilized, and she was listed for urgent liver transplantation. The anhepatic state was managed with intermittent plasmapheresis. She had transplantation 72 hours later, and was discharged from the hospital 3 weeks postoperatively after an uneventful recovery. She remains disease-free and has normal liver function 8 months after transplantation.

Management of the gastrointestinal tract and nutrition in patients with cloacal exstrophy

Cloacal exstrophy is a rare condition in which there is a complex set of congenital anomalies that affect multiple-organ systems, including the gastrointestinal tract. Twenty-six patients with cloacal exstrophy have been treated at the authors' institution during the last 20 years. Gastrointestinal features usually included omphalocele, exstrophy of an everted cecal plate, a short blind-ending distal colon, imperforate anus, and, occasionally, a shortened small bowel. Additional gastrointestinal anomalies included four cases of colonic duplication, one duodenal web, and one malrotation. The average time until the initiation of enteral feeding after initial surgery was 15.6 days, and the time until discontinuation of total parenteral nutrition (TPN) was 36 days. One patient with short bowel syndrome died of TPN-associated liver failure. Five other patients exhibited short bowel physiology, but ultimately each was weaned from supplemental intravenous hyperalimentation. Four patients have undergone posterior sagittal anorectoplasty, and one has had perineal anoplasty. Of these patients, two are continent and one is free of soilage on a bowel management program. In the authors' experience with management of the gastrointestinal tract and nutrition in patients born with cloacal exstrophy, many patients initially exhibited short bowel physiology, although most eventually adapted. However, very few patients have been able to achieve bowel control.

Credentialing of research surgeons: can computers help in the process?

There has been recurring debate regarding the need for a process of ensuring that individuals who propose research using live animals will be competent in the research and compassionate in their care of animals. The mechanism by which this goal can be accomplished is presently under consideration and acceptance by investigators is of concern. As a first step, the authors propose utilization of an interactive computer program that not only would evaluate cognitive knowledge but also would instruct in areas found to be deficient. Immediate feedback with educational reinforcement is possible. The authors' interest in such a program began with a pediatric surgical postgraduate course presented in 1994 at the Clinical Congress of the American College of Surgeons. The computer program utilized was IRIS (Instantaneous Response Interactive System: IRIS, Denver, CO, USA). This system was well suited to evaluation and instantaneous feedback. That program, or one like it, would be suited to initial evaluation and education of researchers. The important aspect is interaction and immediate feedback. This article also includes the results of a panel discussion at the annual meeting of the Academy of Surgical Research in Albuquerque, New Mexico.

Thoracoscopic management of empyema in children

The appropriate management of empyema in children is controversial. Traditional surgical approaches have included thoracotomy and open drainage, decortication, and thoracoplasty. While generally effective, these procedures can be associated with considerable morbidity. We have sought to assess the utility of video-assisted thoracoscopic adhesiolysis and pleural debridement for the treatment of empyema in children. Nine children with postpneumonic empyema unsuccessfully managed with a single attempt at closed tube thoracostomy underwent thoracoscopic drainage during the past 2 years. The empyema was successfully treated with this technique in seven patients with no further interventions being required. Procedures performed early in the fibrinopurulent stage were technically easier. The average time before chest tube removal was 8.5 days. An immunocompromised patient required a subsequent open decortication and a patient with a coagulopathy required two subsequent open procedures for drainage of a recurrent hemothorax. We conclude from this experience that video-assisted thoracoscopic adhesiolysis and pleural debridement can be successfully performed in children. Benefits include good visualization of the entire thoracic cavity for more effective debridement and efficient drainage, and subjectively diminished postoperative pain and associated morbidity.

Intestinal perforation due to an ingested foreign body: laparoscopic management

The authors report the case of a previously healthy 10-year-old boy who accidentally ingested a toothpick. He presented to the hospital 7 days after the incident with left lower quadrant abdominal pain and fever; there was evidence of localized peritoneal irritation by exam. He had mild leukocytosis. An abdominal CT scan showed the toothpick in the sigmoid colon with extension through the bowel wall. Laparoscopic exploration was undertaken and an 8-cm toothpick was identified and removed from the perforation site in the sigmoid colon. Via a small suprapubic incision the sigmoid was delivered and repaired. The patient had an uneventful recovery and was discharged home 2 days after the procedure.Laparoscopic exploration can be diagnostic and therapeutic in the management of ingested foreign bodies with suspected intestinal perforation.

Laparoscopic oophorectomy in children

Laparoscopy is a well-established diagnostic and therapeutic modality for adult gynecologic surgery. We have sought to assess the feasibility of the laparoscopic approach to a particular gynecologic procedure, oophorectomy, in the pediatric population. Five patients under-went laparoscopic oophorectomy during the past year. The indication for oophorectomy in three cases was ovarian torsion---one in association with a hemorrhagic cyst another with a benign teratoma, and one that occurred prenatally. The fourth patient had a teratoma with significant solid component and the final patient was a young with Turner's syndrome who had laparoscopic exploration and removal of bilateral streak ovaries. Oophorectomy was successfully completed laparoscopically in each patient. In two cases a trocar site had to be widened to remove the specimen from the abdominal cavity. Post operative recovery was prompt, with time to discharge being an average of 2 days. From this experience we conclude that laparoscopic oophorectomy can be successfully accomplished in infants and children. It is technically an easy procedure and has the benefits of excellent visualization of the entire lower abdomen and pelvis including the contralateral ovary, rapid postoperative recovery, and good cosmetic result.

Epstein-Barr virus-associated hepatic smooth muscle neoplasm in a cardiac transplant recipient

Host immunosuppression is increasingly recognized as a significant risk factor for the development of a primary neoplasm. Chronic immunosuppressive therapy, as used in organ transplantation, may perturb the immunosurveillance ability of the host, making the patient more susceptible to virus-associated malignancies. We have taken care of a care of a child who received an orthotopic heart transplant and who then developed both a generalized lymphoproliferative disorder and a leiomyoma of the liver a year later. Epstein-Barr virus DNA was detected in a lymph node initially and the hepatic tumor cells subsequently. The former responded to a reduction in the immunosuppressive medications and the latter responded to surgical resection. This is the first report of a hepatic smooth cell neoplasm occurring following cardiac transplant and the development of two sequential Epstein-Barr virus-associated disorders in an immunosuppressed patient.

Octreotide does not prevent bacterial translocation in an infant piglet model of intestinal ischemia-reperfusion

The process of bacterial translocation (BT) after ischemia/reperfusion (I/R) injury is reported to be mediated by local mucosal factors, the effects of pancreatic enzymes, epithelial disruption, and by dysfunctional intestinal motility. Octreotide (OCT), a somatostatin analog, has been postulated to protect against BT by influencing one or more of these factors. Twenty-two formula-fed piglets (weight, 3.5 +/- 0.5 kg; age, 20 +/- 5 days) were divided into four groups: control (no drug given; no I/R; n = 6), I/R (no drug given; n = 5), I/R plus low-dose OCT (LD OCT, 0.08 microgram/kg; n = 6), and I/R plus high-dose OCT (HD OCT, 8 micrograms/kg; n = 5). All experimental subjects had nonocclusive mesenteric ischemia induced by reversible pericardial tamponade with mesenteric flow decreased to 25 +/- 5% of baseline for 5 hours followed by 15 +/- 5 hours of reperfusion. Mesenteric lymph nodes (MLN), liver, spleen, blood, and peritoneum were harvested for blind microbial analysis. None of the animals in the control group experienced translocation to the tissues tested. All of the animals in the I/R group experienced BT to the MLN. The subjects in the LD OCT and HD OCT groups experienced BT to the MLN 66% and 80% of the time, respectively. Despite the reported clinical evidence that OCT can protect the intestinal mucosa from injury and increase the clearance of bacteria from the gastrointestinal tract, in this study in which variables other than I/R known to promote bacterial translocation were eliminated, OCT failed to modify or prevent the occurrence of translocation to the MLN after I/R injury.

Bacterial translocation in mesenteric ischemia-reperfusion injury: is dysfunctional motility the link?

The authors previously reported that mesenteric ischemia and reperfusion (I/R) in a chronic newborn piglet model creates dysfunctional intestinal motility. Whether this leads to inadequate bacterial clearance and translocation (BT) through the gastrointestinal tract remains unclear. To test this hypothesis the authors used their chronic piglet model (weight, 3.5 +/- 0.3 kg; age, 18 +/- 4 days; on formula feeding); nonocclusive mesenteric ischemia was induced via reversible pericardial tamponade. Mesenteric flow (SMA Doppler measurement via the retroperitoneal approach) was decreased to 25% +/- 5% of baseline for 300 minutes in the ischemia group (n = 7) and followed by 14 hours of reperfusion in the I/R group (n = 6). Control subjects had a sham operation (n = 7). Mesenteric lymph nodes (MLN), liver (L), spleen (S), ileum, peritoneum, and blood were harvested for blind quantitative microbial analysis. Subjects in the control group had no cultures positive for growth. Eighty-five percent of animals in the ischemia group had positive MLN cultures only (P < .05 v control). All piglets in the I/R group had positive MLN cultures (P < .05 v control), and one third of them manifested bacteremia. Histological examination did not show mucosal disruption in any group. The validity of this model is confirmed by the negative cultures in the control group and by the presence of normal ileal flora in all animals. In the ischemia and I/R groups, MLN cultures were consistently positive with gram-negative bacilli (Escherichia coli and/or Klebsiella pneumoniae). When subjects of the I/R group had more than 1,000 colonies in the MLN, bacteremia with the translocating organisms was also identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastroesophageal reflux in children

Operations for the control of complicated gastroesophageal reflux in children are commonly performed procedures in large pediatric centers. The comprehensive diagnostic scheme includes radiologic and endoscopic work-up coupled with extended pH probe analysis. Medical therapy remains the principle form of management, with surgery reserved for treatment failure.

Ovarian masses in children: a review of 91 cases of malignant and benign masses

Ovarian masses in children are uncommon. We reviewed all cases of ovarian masses presenting to this hospital from 1979 to 1990. Ninety-one patients fulfilled the criteria and had medical records available. All patients were less than 18 years old. Four were diagnosed antenatally. Thirty-four tumors presented prior to 8 years of age and 1 (2.9%) was malignant. Fifty-eight tumors presented after 8 years of age and 18 (33%) were malignant. Seventy-two patients had benign disease and 19 had malignant tumors. Of those with benign disease 22 had simple or epithelial cysts, 25 had teratomas, 13 had torsion with cyst formation, 3 had granulosa cell tumors, and 9 had other less common lesions. Analysis of symptoms could not distinguish between benign and malignant lesions; however, age was less (P < .03) and tumor size smaller (P < .001) in patients with benign lesions. Benign lesions presented at a mean age of 8.8 years. Fifty-four patients had an ultrasound, all were diagnostic: simple mass (14), complex mass (8), or cyst (32). Mean size of the masses was 9.5 x 7.7 cm. Fourteen patients had a contralateral ovarian cyst. The malignant lesions included 14 germ cell tumors (4 endodermal sinus, 4 teratoma, 2 choriocarcinoma, 2 dysgerminoma, 1 embryonal, and 1 mixed), 4 epithelial tumors (1 mucinous cystadenocarcinoma, papillary cystadenocarcinoma, papillary serous cystadenocarcinoma, and endometrioid adenocarcinoma), and one patient with leukemic infiltration (ALL). Germ cell tumors presented at a mean age of 11.8 years. Eight of these patients had an ultrasound and all showed a mass (7) or cyst (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Mesenteric ischemia in hypoplastic left heart syndrome

Hypoplastic left heart syndrome (HLHS) has been widely viewed as a uniformly fatal form of congenital heart disease. Between January 1984 and December 1990, 387 patients with the diagnosis of HLHS were treated at this institution. Mesenteric ischemia was clinically diagnosed in 31 patients (8% incidence) and confirmed by pathology or surgery in 25 of those patients. The mean age at the time of onset was 17.5 +/- 5.4 weeks and only 13% were premature newborns. In 80% of the patients a low perfusion state and significant hypotension were documented within 48 hours prior to the diagnosis of bowel ischemia. Nine patients (29%) required operative intervention (bowel resection 4, diffuse ischemia 3, and simple drainage 2). Overall, at operation or at autopsy, nine patients (29%) had diffuse gastrointestinal ischemia. Of 31 patients with mesenteric ischemia, 26 children (84%) died shortly after onset of the gastrointestinal symptoms regardless of means of management. Five patients (10%) initially improved with aggressive medical and/or surgical management; however, 4 subsequently died secondary to complications of their primary cardiac disease. Therefore, the overall mortality of patients with mesenteric ischemia was 97%. Previous reports have estimated that up to 7% of full-term newborns with symptomatic congenital heart disease may develop necrotizing enterocolitis (NEC). Our unique group of patients with HLHS is comprised mostly of full-term infants who developed onset of mesenteric ischemia at a mean age of 4 months associated with an underlying low perfusion state. This mesenteric ischemia has been erroneously identified as NEC.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of ischemia and reperfusion on intestinal motility

The interdigestive migrating motor complex (MMC) has been demonstrated to be a reliable indicator of intestinal motility and function. The effects of low perfusion on the MMC have never been studied. Fourteen newborn Yorkshire piglets (5 to 18 days old, weighing 2.9 +/- 0.4 kg) underwent celiotomy under general anesthesia with placement of four jejunal electrodes (50 cm apart) as well as a superior mesenteric artery (SMA) Doppler flow probe and a pericardial catheter. Group 1 (n = 5) had operation alone. Group 2 (n = 9) had nonocclusive mesenteric ischemia induced by reversible cardiac tamponade for 5 hours between postoperative days 6 to 12. All subjects had MMC phase III electrical activity, cycling time, and propagation velocity recorded daily. In group 2 MMCs were recorded prior to and during ischemia, and during reperfusion. Group 2 animals had 75% +/- 4% decrease in SMA flow during the tamponade period. During the ischemic period, the MMC cycling time (CT) increased from 67 +/- 10 (mean +/- SEM) to 98 +/- 12 minutes (P < .05) and MMC propagation velocity (PV) decreased to 4.2 +/- 2.2 from a baseline value of 10.5 +/- 1.5 cm/min (P < .05). During reperfusion CT and PV values were not significantly different from baseline. The validity of this model is confirmed by the comparable baseline recordings in groups 1 and 2, and by the return of MMC to baseline values within 4 to 7 hours of reperfusion, as seen in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic aneurysm associated with fibrointimal proliferation of the common carotid artery following blunt trauma: case report

Late neurologic symptoms following blunt trauma to the neck and upper torso were evaluated with duplex scanning of the carotid arteries and the diagnosis of a traumatic aneurysm of the common carotid artery with an associated stenosis was made. Resection and an end-to-end anastomosis resulted in an excellent outcome. Carotid aneurysm following blunt trauma is unusual and duplex scanning facilitated the diagnosis. Duplex scanning is useful in the evaluation of the carotid arteries in patients with posttraumatic neurologic symptoms.

Mesenteric, omental, and retroperitoneal cysts in children: a clinical study of 22 cases

Cystic lesions of the mesentery, omentum, and retroperitoneum are rare; from 1956 to 1990, 22 patients had operative treatment for such lesions at our institution. They ranged in age from 1 month to 14 years; 75% were younger than 5 years. All had either an acute abdomen or, more commonly, a silent abdominal mass. In all cases, the histologic diagnosis was lymphangioma. Abdominal ultrasonography was done in all cases after 1977 except for two patients who had an acute abdomen requiring emergency exploration. A cystic abdominal mass was diagnosed in 94% of these cases, but the correct diagnosis of lymphangioma was made prior to surgery in only 24%. Mesenteric cysts are most common in the small bowel mesentery. Omental cysts usually occur singly and are easily resected, but multiple cysts predominate in the mesentery and retroperitoneum. Complete resection was accomplished in 82% of our cases. Two patients required partial bowel resection, and four had partial excision with marsupialization of the cysts. With a mean follow-up of 23 months, we have had three recurrences, but none necessitated reexploration. Extra-abdominal lesions, mainly cutaneous lymphangiomas, developed in two cases. Prognosis is good after surgical excision, but long-term follow-up is advisable because of the possibility of recurrence, even during adulthood.

Systemic and mesenteric vascular effects of platelet-activating factor and cocaine. In vivo effects on a neonatal swine model

Mesenteric hypoperfusion may be responsible for alterations in gut mucosa leading to necrotizing enterocolitis. Platelet-activating factor (PAF) and cocaine have been implicated in the etiology of necrotizing enterocolitis. We have demonstrated direct toxic effects of these compounds in vitro, but the in vivo mechanism of bowel damage is unknown. Newborn piglets (3.0 +/- 0.3 kg) had physiologic parameters (electrocardiogram, blood pressure, pulse, and central venous pressure) continuously monitored as well as Doppler probe recordings of superior mesenteric artery flow (Qsma). Aortic flow with calculation of cardiac index, and systemic and mesenteric vascular resistances (SVR and MVR) were also determined. Group 1 (N = 8) received PAF (0.5 microgram/kg). Groups 2 (N = 8) and 3 (N = 8) received high (17 mg/kg) and low (9 mg/kg) doses of cocaine, respectively. Each subject served as its own control. Histology demonstrated edema or early mucosal hemorrhage in all groups. PAF caused a third-degree atrioventricular block of short duration and a prolonged decrease of the cardiac index, but only a brief elevation of SVR and MVR. The cocaine groups had a sustained increase of SVR and MVR associated with a decrease of cardiac index. The decrease of Qsma paralleled the changes of MVR in each subject. These data show that both PAF and cocaine induce mesenteric ischemia. The effect of PAF is of short duration and mainly related to its cardiotoxic effects resulting in low Qsma. Cocaine causes an increase in MVR with prolonged depression of mesenteric flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon tracheoplasty in children: results of a 15-year experience

Strictures of the trachea traditionally have been dilated by antegrade bouginage. This method not only dilates but imparts a shearing force to the wall of the trachea. The resultant trauma may contribute to further scarring and aggravation of the stricture. We report a 15-year experience with 37 patients and 158 tracheal dilatations using balloon catheters that impart only radially directed forces and can be precisely placed and gradually inflated. Various adjunctive techniques have been performed, including: (1) electrocautery of granulation tissue; (2) parenteral and local use of steroids; and (3) intraluminal stenting after dilation. Recent experience indicates that this combination of methods is important in improving patient outcome. The principal indications for balloon tracheoplasty include acquired tracheal stenosis from various causes, and congenital subglottic stenosis. Almost all patients received some immediate benefit from balloon tracheoplasty. Fifty-four percent of the patients achieved long-term improvement (with a minimum follow-up of 2 months). Additionally, 10 of 20 children who had been unable to previously tolerate removal of an indwelling tracheostomy tube proceeded to extubation. We have had poor success in treating bronchial and glottic stenosis. Endoscopically directed hydrostatic balloon tracheoplasty is a safe and effective method for the treatment of tracheal stenosis of varying causes. Multiple dilatations are required that gradually improve the character of the tracheal lumen. In selected cases, the procedure may delay or avoid the need for an open tracheoplasty.

Human immunodeficiency virus and the surgeon

To assess the exposure risks for surgeons and nurses treating HIV infected patients at the Medical University Hospital and the Charleston Memorial Hospital, a retrospective review of HIV positive patients who underwent surgical procedures from 1985-1988 was undertaken. During that period, 150 patients tested positive for HIV of which 30 (20%) underwent 19 surgical procedures. The prevalence of HIV infected patients at our institution has been increasing over the last two years. 5.3% of the patients tested were positive for the virus. Evidence of drug abuse was not a predictive factor of HIV infection but homosexuality was present in 57% of our patients. The mean age of the surgical group was 34 years. Seventy-three percent of the patients underwent minor operations and 27% had major surgical procedures. Almost half of the operations were performed to treat an AIDS-related complication or as a diagnostic aid in the workup of the AIDS patient. Major operations performed were for treatment of a co-morbid condition not related to the HIV infection. Only two patients had operations for trauma. Operative mortality was 10% but no death was directly related to surgical intervention. In addition to universal precautions in the pre and postoperative period, operating room personnel must follow established protocols in the conduct of the operation to ensure the safety of all staff.