Life on the farm-children at risk

BACKGROUND

More than 1 million children live, play, and work on farms, surrounded by animals and machinery. This symbiotic relationship between work and home exposes children to unique risks.

METHODS

Children presenting with a farm-related injury (November 1994 to August 2001, 82 months) were included. Trauma registry parameters included injury severity score (ISS); Glascow Coma Scale (GCS); time to presentation; season and day of injury; emergency room, intensive care unit, and total length of stay type; and mechanism of injury; and operations.

RESULTS

A total of 1,832 pediatric trauma patients were evaluated. Ninety-four children were identified with farm-related injuries. Mean age was 10.75 years. Mean ISS was 7.38. Three children died. Four children wore protective equipment. Forty-four percent of injuries occurred during summer, 31% during spring, and 55% on weekends. Average time to initial presentation was 39 minutes. A total of 177 minutes elapsed before transfer to regional trauma center. Seventy-two children required admission. LOS was 0 to 28 days, mean, 2.76 days. Twenty-six children (28%) required operations. Injuries included dislocations/fractures (52%), lacerations/avulsions (38%), concussions (31%), contusions (30%), and burns (14%). Mechanism included animals (41%), falls (34%), motor vehicles (28%), all-terrain vehicles (20%), and firearms (4%).

CONCLUSIONS

Farm injuries occur most commonly during weekends, summer, and spring months, resulting in significant morbidity. Most injuries required hospitalization. Unless unstable, initial transfer to a regional pediatric trauma center should result in the most cost-effective, prompt, and highest quality of care.

Computed tomography and ultrasonography in the diagnosis of appendicitis: when are they indicated?

HYPOTHESIS

Relative merits and indications exist for ultrasonography (US) and computed tomography (CT) in the diagnosis of appendicitis.

DESIGN

Prospective study.

SETTING

General community and tertiary care hospital.

METHODS

Ninety-nine patients (50 males and 49 females) were studied. Following consent, the initial disposition was recorded, designating the patient for operation, observation, or discharge from the hospital. Each patient was studied by CT and US. Studies were independently evaluated by 2 radiologists, and the results were designated as positive, negative, or equivocal. The surgeon reevaluated patients before and after learning the results of US and CT, recording whether the CT scan, US, or reexamination influenced the final disposition.

RESULTS

Fifty patients had appendicitis; 6 appendixes were perforated. The initial clinical impression called for 44 operations, 49 observations, and 6 discharges. Thirty-four patients had their treatment plan changed from the initial disposition. Ultrasonography did not affect the initial impression. In contrast, 18 patients were rediagnosed solely on CT scan findings. Seven patients were rediagnosed by reexamination. Of 44 patients initially designated for operation, the CT scan and reexamination spared 6 females from surgery; the negative appendectomy rate potentially decreased from 50% to 17% (P =.03). The CT scan, US, or reexamination failed to spare 2 males from exploration with negative results. Of the 49 patients initially designated for observation, 23 were rediagnosed after reevaluation, 13 were discharged from the hospital, and 10 underwent expedient operation. One patient was spared from inappropriate discharge from the hospital. The reliability of the CT scan was good, with high sensitivities and specificities. Equivocal scan results lowered the diagnostic value.

CONCLUSIONS

Selective use of a CT scan with a second examination can improve the diagnostic accuracy and management of suspected cases of appendicitis by (a) reducing the negative appendectomy rate in females, (b) moving patients from observation to earlier operation or discharge from the hospital, and (c) preventing inappropriate discharge of patients with appendicitis.

Fall injuries in the pediatric population: safer and most cost-effective management

BACKGROUND

At our children's hospital, 30% of all trauma admissions are from falls. The aim of this study was to outline inefficiencies and unnecessary costs incurred in the care of these patients.

METHODS

The charts of 127 children admitted for falls (height > or = 9 feet) from 1993 to 1996 were reviewed. Patient demographics, injuries, and treatment costs were recorded and analyzed.

RESULTS

Fifty-seven children (45%) were evaluated at an outside facility before transfer. Of these, 73% had injuries requiring treatment at the pediatric center. Local hospital work-up resulted in an average treatment delay of 4.5 hours. Additionally, significant cost was incurred by duplication of radiographic studies, the majority of which were normal.

CONCLUSION

Improved and more cost-effective care in pediatric falls can be ensured by immediate transfer of patients with significant injuries, omission of radiographs before transfer, and avoidance of multiple routine x-ray films, the majority of which are normal.

Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma

BACKGROUND

Focused abdominal sonography for trauma (FAST) has been well reported in adults, but its applicability in children is less well established. We decided to test the hypothesis that FAST and computed tomography (CT) are equivalent imaging studies in the setting of pediatric blunt abdominal trauma.

METHODS

One hundred seven hemodynamically stable children undergoing CT for blunt abdominal trauma were prospectively investigated using FAST. The ability of FAST to predict injury by detecting free intraperitoneal fluid was compared with CT as the imaging standard.

RESULTS

Thirty-two patients had CT documented injuries. There were no late injuries missed by CT. FAST detected free fluid in 12 patients. Ten patients had solid organ injury but no free fluid and, thus, were not detected by FAST. The sensitivity of FAST relative to CT was only 0.55 and the negative predictive value was only 0.50.

CONCLUSION

FAST has insufficient sensitivity and negative predictive value to be used as a screening imaging test in hemodynamically stable children with blunt abdominal trauma.

Infarction of the choledochus, liver, gallbladder, and pancreas: a unique complication of the hemolytic uremic syndrome

Hemolytic uremic syndrome (HUS) is associated with multiple nonrenal manifestations. A unique case is described of a 3-year-old boy who presented with a classic diarrheal prodrome followed by massive necrosis of the biliary tree and common bile duct, pancreas, and the left lobe of his liver. This complication of HUS has not been reported in the English-language literature.

Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?

BACKGROUND/PURPOSE

Most pediatric surgeons and pediatric radiologists consider computed tomography (CT) the best radiological test for the evaluation of children with suspected intraabdominal injury. The majority of injured children evaluated with CT will be found to have a normal scan. Focused abdominal sonography for trauma (FAST) has been shown to be a useful screening test in the evaluation of adult patients with suspected intraabdominal injury. Limited data exist regarding the use of FAST in children. Our aim was to evaluate the usefulness of FAST as a screening test in the evaluation of children with suspected intraabdominal injury in an attempt to minimize the number of normal CT scans performed.

METHODS

Hemodynamically stable children evaluated for suspected intraabdominal injury were prospectively screened with FAST. FAST, real-time sonography at four sites, was performed by staff pediatric radiologists. The average duration of the examination was 2 minutes. Positive and negative FAST scan findings were defined prospectively. The result of each FAST was recorded (positive or negative) and then all patients underwent CT as a control. All management decisions were based on CT results.

RESULTS

Forty-six patients were included in the study. FAST identified four children with positive findings (free intraperitoneal fluid), whereas CT showed 13 children with injuries (nine with associated free intraperitoneal fluid and four with only solid organ injury and no associated intraperitoneal fluid). There were nine false-negative and no false-positive FAST scans. The sensitivity of FAST was 0.3 and the specificity was 1.0. Injuries missed by FAST included liver laceration, adrenal hematoma, renal laceration, small bowel injury and splenic laceration.

CONCLUSION

Preliminary results suggest that FAST alone is not a useful screening test in the evaluation of children with suspected intraabdominal injury.

Nonteratomatous germ cell tumors in children

BACKGROUND/PURPOSE

Totipotential germ cells may give rise to a broad range of tumors. The teratomatous variety of germ cell tumors has been the subject of several large studies. The goal of the current study was to describe the clinical features of nonteratomatous germ cell tumors (NTGCT) by reviewing a large series of patients.

METHODS

Between 1945 and 1997, there were 78 cases of nonteratomatous germ cell tumors (NTGCT's) in children at The Children's Hospital, Columbus. Their records were reviewed retrospectively. There were 35 boys and 43 girls (M:F ratio 0.8). Mean follow-up was 87 months.

RESULTS

Histological subtypes included germinoma (33 cases, 42%), endodermal sinus tumor (24 cases, 31%), embryonal carcinoma (12 cases, 15%), gonadoblastoma (4 cases, 5%), mixed histology (4 cases, 5%), and choriocarcinoma (1 case, 2%). Forty-two tumors were in gonadal sites, but a significant percentage were extragonadal (36 cases, 46%). Forty-six patients (59%) had localized disease, 18 (23%) had regional disease, and 14 (18%) had metastases. Treatment consisted of surgery and selective chemotherapy and radiation. Complete tumor resection was more likely for gonadal (29 of 42, 69%) than extragonadal primaries (15 of 36, 41%; P < or = .05). Forty-nine (63%) of all patients survived, whereas 29 (37%) died of their disease. Survival in patients with gonadal primaries (32 of 42, 76%) exceeded that in patients with extragonadal primaries (17 of 36, 47%; P < or = .01). Survival in patients with localized disease (34 of 46, 74%) exceeded that in patients with regional extension or metastases (15 of 32, 47%; P < .05).

CONCLUSIONS

This study highlights the fact that tumor location, gonadal versus extragonadal, was important in determining prognosis, whereas tumor histology was not. This may be the result of a higher rate of complete tumor resection for gonadal primaries and underscores the important role of surgery in the optimal treatment of these unusual tumors.

The childhood air gun: serious injuries and surgical interventions

OBJECTIVE

Increasingly powerful nonpowder firearms or air guns are frequently given to children as toys. We undertook the present study to evaluate the injuries caused by these firearms, based on the concern that they are capable of inflicting serious trauma.

DESIGN

Descriptive, retrospective chart review.

SETTING

Urban level I pediatric trauma center.

PARTICIPANTS

The study included all children with injuries secondary to air guns who were admitted between July 1988 and March 1995.

MAIN OUTCOME MEASURES

Type of weapon, circumstances of injury, anatomic location of injury, injury severity, surgeries performed, morbidity.

INTERVENTIONS

None.

RESULTS

There were 42 admissions with a mean hospital stay of seven days (range 1 to 136 days). The average age was 10 years (range 1 to 23 years) with a median age of 11 years. There were 35 boys and 7 girls. Twenty-nine of the 42 injuries were caused by a family member or friend and five were self-inflicted. The mean injury severity score was 8.3. While there were no fatalities, 21 children (50%) underwent operative procedures for their injuries. Ten of the injuries were potentially lethal, of which seven were due to the "pump" action air gun. Sixteen patients had serious long-term disability as a result of their injuries.

CONCLUSION

Air guns can cause a variety of serious injuries, often requiring operative intervention. The long-term morbidity from some of these injuries is significant. Both parents and physicians should be aware that nonpowder guns are not toys, but weapons capable of inflicting serious trauma. The evaluation and treatment of air gun injuries should be similar to that currently used for powder weapon injuries. Recommendations for evaluation and treatment are made.

Alimentary tract malignancies in children

Alimentary tract malignancies in children are unusual. From 1952 to 1996, 54 patients (55 cases) underwent surgery at The Children's Hospital, Columbus for intestinal malignancy. Their records were reviewed retrospectively. The mean age at diagnosis was 9.3 years (range, 1 to 17 years). There were 35 boys and 19 girls (M:F ratio, 1:8). Mean follow-up was 108 months. Laparotomy was performed in all but one child. The primary tumor sites included the colon (31 cases), small bowel (12 cases), appendix (9 cases), and stomach (3 cases). Seventy-five percent of the tumors were non-Hodgkin's lymphomas (41 cases), followed by appendiceal carcinoid (9 cases), colon adenocarcinoma (3 cases), and gastric sarcoma (2 cases). Lymphoma occurred in 28 of 31 nonappendiceal large bowel tumors and was the only tumor type seen in the small intestine. There were 21 Burkitt's, 11 lymphoblastic, 6 small cell, and 5 large cell lymphomas. There was a statistically significant increase in the frequency of small bowel lymphoma after 1982 (10 of 20) in comparison with that before 1982 (2 of 21), P < .05. This coincided with an increase in Burkitt's lymphoma from 5 of 21 (pre-1982) to 16 of 20 (post-1982), and a decrease in lymphoblastic lymphomas from 7 of 21 (pre-1982) to 2 of 20 (post-1982), P < .05. Localized disease and complete resection favored survival in lymphoma, whereas age, sex, and urgency of operation had no influence on survival. This study highlights the predominance of lymphoma as the most common small and large bowel tumor and highlights the emergence of nonendemic Burkitt's as a major entity in pediatric intestinal malignancy.

Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important?

OBJECTIVE

To assess the incidence and consequences of small bowel injury (SBI) in children suffering blunt abdominal trauma managed with the intent to treat nonoperatively.

DESIGN

Retrospective chart review.

MATERIALS AND METHODS

A total of 168 consecutive hemodynamically stable children admitted to a Level I pediatric trauma center during a 24-month period.

RESULTS

Nine of 168 children (5%) sustained SBI: three underwent early (< 4 hours) operation for recognized SBI (identified on computed tomographic scan); and six had delayed (36 +/- 16 hours) operation for missed SBI (not identified on computed tomographic scan). Increased temperature and heart rate, or decreased urine output at 24 hours suggested occult SBI. The hospital course was unaltered by delayed diagnosis. Fifty-seven percent of the children (95) suffered intra-abdominal injury; 10% required laparotomy for SBI (9) or solid organ injury (7); 90% (152) were discharged without laparotomy.

CONCLUSIONS

SBI is uncommon in children suffering blunt abdominal trauma. The diagnosis can be made using clinical and radiographic findings. Limited diagnostic delay does not seem to affect outcome. We conclude that clinical diagnosis of SBI is safe, permits the nonoperative treatment of most blunt abdominal injuries, and reduces the risk of unnecessary laparotomy associated with alternate approaches.

Unique protein expression by the TBJ clonal derivative of C1300 murine neuroblastoma

C1300 is a murine neuroblastoma that arose spontaneously in an A/JAX mouse, and from which a clone termed TBJ was subsequently derived. C1300 is a slowly growing and poorly metastasizing tumor, whereas TBJ shows early systemic metastasis as well as aggressive local growth. Compared with TBJ cells, C1300 cells are highly immunogenic and are sensitive to natural killer cells and cytotoxic lymphocytes. In vitro, TBJ cells were found to be more rounded and less adherent than C1300 cells. Because the underlying basis for the differences between C1300 and TBJ cells has not been fully elucidated, the authors used high-resolution two-dimensional gel electrophoresis (2-DE) to study comparative aspects of total protein expression by each cell line. Of the approximately 400 individual cellular proteins that could be resolved using this technique, two were found to be reproducibly and uniquely expressed by TBJ cells and not by C1300 cells. Both proteins were anionic (pl 5.0 to 5.2) as assessed by iso-electric focusing and had molecular weights of 76,000 and 82,000 as assessed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Silver staining of SDS-polyacrylamide gels showed that the levels of 82,000-M(r) protein (p82) were higher than those of the 76,000-M(r) protein (p76). A purification protocol allowing for the isolation of p82 from TBJ cell extracts was developed, which comprised preparative two-dimensional gel electrophoresis followed by reverse-phase high-performance liquid chromatography. Full molecular identification of p82 and p76 eventually may provide new leads in the study of the metastatic or antigenic properties of neuroblastoma.

Penetrating neck trauma in children: a reappraisal

The management of penetrating neck injuries in adults is controversial, with a trend toward selective neck exploration. These injuries are uncommon in children, and only limited information exists regarding their management. To assess the management of these injuries in the authors' geographic region, they reviewed the records of children with injuries penetrating the platysma muscle who were treated between 1980 and 1994. Forty-six children (aged 2 to 16 years) suffered a total of 55 penetrating neck injuries. The injuries were classified according to type and location. Fifty-two percent were caused by missiles, 30% by stab wounds, and 18% by dog bites. Fifty-eight percent of injuries were in zone II, 31% in zone I, and only 11% in zone III. The diagnostic workup, including arteriography, esophagography, or endoscopy, was performed preoperatively in 10 patients. Overall, 21 patients had exploration, and the rate of negative explorations was 48%. All cases explored for bleeding or a positive diagnostic workup result were found to have significant injury. On the other hand, all neck explorations performed solely because of injury to zone II were negative. The overall morbidity and mortality rates were 31% and 7%, respectively. A more selective approach, similar to that used for adult patients, emphasizing preoperative diagnostic evaluation, is recommended to decrease the rate of negative neck explorations among children.

Evaluation of the pediatric surgical matching program by the directors of pediatric surgical training programs

In a previous survey of successful candidates (SC) and unsuccessful candidates (USC) to the pediatric surgery matching program (PSMP), significant discriminating factors associated with SC included previous participation in basic science research, number of publications, number of national presentations, and contact with and letters of recommendation from well-known pediatric surgeons. The purpose of this study was to determine the selection criteria used by directors of the pediatric surgery training programs (PSTP) in choosing residents for the PSMP. A two-part survey of the PSMP was completed by directors of the PSTP (n = 24) to identify the factors (n = 31) that most influence their selection process when choosing a resident, and to help clarify questions (n = 11) posed by the candidates during the first survey. In part I, each factor was scored on a modified Likert Scale, from most (1) to least (5) important in evaluating candidates for training positions, and were ranked according to the mean score. Based on our previous survey, but blinded to the PSTP director respondents, these same factors were divided into groups that, in our first survey, did and did not discriminate between SC and USC for the PSMP, and will be referred to as "discriminating factors" (DF, n = 7) and "non-discriminating factors" (NDF, n = 8), respectively. Also, a series of questions dealt with subjective factors of the candidates, not previously analyzed in our original survey, and will be referred to as "program directors' factors" (PDF, n = 16). The three groups (DF, NDF, PDF) were analyzed by the Kruskal-Wallis test and analysis of variance (ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)

Combined preoperative and postoperative immunotherapy for murine C1300 neuroblastoma

Preoperative treatment of murine C1300-neuroblastoma (C1300) with triple immunotherapy using low-dose cyclophosphamide (CY), retinyl palmitate (RP), and interleukin-2 (IL2), followed by tumor resection leads to significant initial tumor control and prolonged survival. However, because long-term tumor recurrence is 67%, the efficacy of continued postoperative immunotherapy is now evaluated. Thirty-two A/J mice with 1 cm subcutaneous C1300 tumors were treated for 13 days with CY-100 mg/kg, intraperitoneally (IP), on day 2 of treatment then 25 mg/kg on day 9, RP-2500 IU IP 2 x/week, and IL2 1.6 x 10(5) U IP BID on days 4 to 9 and 11 to 13. On day 14, mice were divided into five treatment groups: (1) OP (operated-tumor resection, n = 6); (2) OP+CY (resection and postoperative CY, n = 7); (3) OP+CY+RP (resection and postoperative CY+RP, n = 7); (4) OP+CY+RP+IL2 (resection and postoperative CY+RP+IL2, n = 7); and (5) CY+RP+IL2 (continued CY+RP+IL2 with no resection, n = 5). Survival and postoperative tumor recurrence were followed for 60 days. The cure rates were group 1 33% (2/6), group 2 43% (3/7), group 3 29% (2/7), group 4 71% (5/7), and group 5 20% (1/5). After surgery, tumors that recurred did so in 8 to 22 days, with no statistical difference noted between groups. MHC class I antigenic expression of tumors resected on day 14 and recurrent tumors was determined with monoclonal antibodies and flow cytometry. In tumors resected on day 14, class I expression measured by mean fluorescence, was 374.8 +/- 27.40.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiology of congenital diaphragmatic hernia II: the fetal lamb CDH model is surfactant deficient

The high mortality for congenital diaphragmatic hernia (CDH) has been attributed to a combination of pulmonary hypoplasia and pulmonary hypertension. We hypothesize that a surfactant deficiency may in part be contributing to the pathophysiology of CDH. This study documents the functional, quantitative, and qualitative aspects of the surfactant status of the alveolar air-liquid interface and the type II pneumocyte in the fetal lamb CDH model. Ten lamb fetuses (gestational age, 80 days) had a CDH created via a left thoracotomy and then were allowed to continue in utero development until term. Three litter mates and three nonoperated time-dated fetuses served as controls. At term, pressure-volume curves were performed to measure pulmonary compliance and total lung capacity. Alveolar lavage was then performed to measure the quantitative and the qualitative aspects of pulmonary surfactant. Finally, isolation of type II pneumocytes allowed quantification of phospholipid synthesis. When compared with controls (N = 6), the CDH lambs (N = 5) had significantly smaller lungs (P = .009), decreased total lung capacity (P less than .001) and compliance (P less than .001), reduced total lavaged phospholipids (P = .006), and decreased percent phosphatidylcholine (P = .02). CDH lambs also had increased total lavaged proteins (P = .05) and higher minimum dynamic surface tension (P less than .001). A surfactant deficiency may be contributing to the pathophysiology of CDH. Surfactant replacement therapy in premature infants has been shown to improve lung compliance, decrease morbidity, and improve survival. Exogenous surfactant may also benefit infants with CDH.

Recombinant human granulocyte colony-stimulating factor promotes wound healing in a patient with congenital neutropenia

We report a patient with congenital neutropenia or Kostmann's Syndrome who suffered many complications after presenting with Clostridium septicum enterocolitis, including absence of wound healing. Because of several reports of the use of granulocyte colony-stimulating factor (G-CSF) in patients with various complications of neutropenia, we treated this patient with recombinant human (rh) G-CSF. We found that once rhG-CSF restored neutrophil counts to normal, progressive wound healing followed. Thus, rhG-CSF therapy may be useful in treating neutropenic patients with wound complications.

Comparative analysis of successful and unsuccessful candidates for the pediatric surgical matching program

Only one third of the applicants for training in pediatric surgery obtain a position through the pediatric surgery matching program. In order to identify factors that contribute to a successful outcome, we conducted a retrospective survey of all participants in the matching process for positions during the years 1983 to 1991. This survey was designed to identify characteristics associated with success in the match through comparison of successful and unsuccessful applicants. Significant factors associated with a successful match included: a greater incidence of residency-supported research (P = .012) with a greater number of publications (P = .003) and national presentations (P = .014), specifically at the annual meetings of the American Pediatric Surgical Association (P = .05) and the American Academy of Pediatrics (P = .05). In addition, successful candidates had more contact with (P = .004) and letters of recommendation from (P = .015) well-known pediatric surgeons involved in the general surgical residency program. This information should be invaluable to those counseling medical students and residents interested in a career in pediatric surgery.

Familial Hirschsprung's disease: report of autosomal dominant and probable recessive X-linked kindreds

Multifactorial sex-modified inheritance has been proposed as the model of transmission in familial Hirschsprung's disease (HD). A review of two separate kindreds suggests that aganglionosis may be inherited as an X-linked recessive or an autosomal dominant trait. Chromosomal anomalies and other syndromes, including G6PD deficiency, may occur with familial HD. Recurrence risk counseling for family members depends on accurate pedigree analysis and a comprehensive understanding of the genetic factors involved.

Enhanced resection and improved survival in murine neuroblastoma (C1300-NB) after preoperative immunotherapy

Advanced neuroblastoma treated with standard chemotherapy has a poor prognosis. Combination immunotherapy for murine neuroblastoma with retinyl palmitate, low-dose cyclophosphamide, and interleukin-2 resulted in increased survival, impaired tumor growth, easier surgical resection, and increased class I expression or tumor cells. Preoperative immunotherapy may be useful in treatment of advanced human neuroblastoma.

The relationship of class I MHC antigen expression to stage IV-S disease and survival in neuroblastoma

Cultured human neuroblastoma cells express low levels of class I (MHC) surface antigen. In order to determine if this low expression is representative of the clinical tumor, this study investigates class I expression in archival human neuroblastoma. Whereas stages I to IV neuroblastoma expressed low levels of class I antigen, stage IV-S tumor cells expressed normal levels, similar to control tissues. Expression of class I antigen in tumors from survivors of stage III neuroblastoma was significantly greater than in tumors from nonsurvivors. Tumors comprised predominantly of ganglion cells expressed significantly more class I antigen than neuroblasts. These data suggest that class I MHC expression may play a role in the natural history of human neuroblastoma.

Postoperative immunotherapy of murine C1300-neuroblastoma

Low-dose cyclophosphamide (CY) is an immunomodulating agent that down-regulates T suppressor cell function. This study investigates postoperative immunotherapy with CY as an alternate treatment for advanced immunogenic tumors such as neuroblastoma that typically respond poorly to traditional high-dose chemotherapy. A/J mice with 1.5-cm subcutaneous C1300-neuroblastoma (C1300-NB) tumors were divided into the following treatment groups: I, untreated (n = 14); II, 85% tumor resection (n = 18); III, sham-operated (n = 18); IV, multiple-dose CY (n = 6); V, 85% resection and single-dose CY (n = 14); VI, 85% resection and multiple-dose CY (n = 14). CY (100 mg/kg, intraperitoneally) was given initially 24 hours post-operatively to groups IV, V, and VI. Groups IV and VI also received weekly maintenance doses of 25 mg/kg CY. Results showed significantly increased survival (log-rank test) in CY-treated groups (IV, V, VI) compared with control groups (I,II,III). Cures were observed only in groups receiving partial resection plus CY (V, 7%; VI, 29%). Although surgical debulking of tumor alone (II) did not enhance survival, the procedure normalized depressed total lymphocyte counts and the subpopulation of Lyt 2,3+ (T suppressor/cytolytic cells) in the immediate postoperative period during which immunotherapy with CY was instigated. This may have contributed to the success of CY immunotherapy. To characterize the tumor-host immune interaction, additional studies were performed. Results showed the following. (1) Mice cured by debulking plus CY (from groups V and VI) could not be successfully reimplanted with C1300-NB, demonstrating immunologic mediation by CY.(ABSTRACT TRUNCATED AT 250 WORDS)

Immune consequences of nonoperative treatment of splenic trauma in the rat model

To investigate the immunologic consequences of non-operative management of splenic injury, three parameters were studied: survival following pneumococcal sepsis, clearance of blood-borne bacteria, following Hemophilus influenzae challenge, and antibody response to type III pneumococcal capsular polysaccharide. Two hundred twenty-five Sprague-Dawley rats were divided into three groups and subjected either to a splenectomy, a sham operation, or standard blunt trauma. A significant increase in mortality was noted in the splenectomized group as compared with both the traumatized and control groups when challenged with Streptococcus pneumoniae. In both the control and trauma groups, H influenzae cleared significantly within 18 hours. Blood-borne bacteria persisted at the same level for 72 hours in the splenectomized animals. Four and 11 days later, the antibody level in both traumatized and control groups was higher than in the splenectomized subjects (P less than .001). There was no difference in the serum antibody level between the control and trauma groups at four days. However, at 11 days the trauma group showed a significant decrease in the antibody level (P less than .05). It can be concluded that following spontaneously-healing splenic trauma in the rat model, survival, bacterial clearance, and antibody response were all superior to that observed in the splenectomized subjects. In addition, the healed splenic disruption did not impair clearance of blood-borne encapsulated bacteria.

The role of pediatric surgery in the medical school curriculum

In most medical schools, exposure to pediatric surgery is presented as a subspecialty elective. We have offered it as an integral part of the surgical clerkship for 10 years in the belief that it provides an excellent educational environment. To confirm this concept, the quizzes (Q), final examinations (FE), and grades of students assigned to the pediatric surgical service were prospectively studied. All students (N = 139) in the surgical clerkship entered the study. Thirty-two students were randomly selected and assigned to the surgical service of a major pediatric hospital (P-Surg) for 50% of their clerkship. The other students (N = 107) were assigned to a variety of adult surgical services (G-Surg) and served as the control group. All students attended the same seminars, used the same educational materials, were examined with the same test items, and were evaluated by the same oral examiners. Test items were electronically scored and the database was analyzed on an IBM computer. The statistical analysis was performed using a Student's t test and chi 2 analysis. There was no significant difference in the demonstrated cognitive performance and grades awarded to the two groups of students. We conclude that a pediatric surgical service provides an atmosphere that is educationally comparable to the adult general surgical service.

Long-term pancreatic-biliary diversion in the rat: persistent loss of mucosal enterokinase, with reinduction by delayed oral pancreatic biliary supplementation

Diversion of pancreatic-biliary (PB) secretions in rats for 23 days led to loss of enterokinase (EK) activity in bypassed segments of the small intestine. Simultaneous oral trypsinogen and bile salt (TB) supplements prevented the loss of EK activity. To study the temporal course of events after PB diversion and to determine if the loss of EK is reversible, PB diversion was performed in rats by surgical transposition of the 4-cm segment of duodenum including the ampulla of Vater to a point 30 cm distal to its original site. Bypassed and control (sham- and nonoperated) rats fed standard rat chow were sacrificed at 10, 23, and 45 days after surgery. One bypassed group was fed standard chow for 23 days and then chow supplemented with TB until sacrifice at 45 days. At sacrifice, the intestines were divided into segment 1 (the bypassed proximal 30 cm) and segment 2 (the 30 cm distal to the bypass). In segment 1, EK disappeared almost completely by 10 days and remained at the same low levels at both 23 and 45 days (p less than 0.05). No significant changes in EK levels were found at any time in segment 2 distal to the bypass. Mucosal disaccharidase activity in segment 1 increased or showed no change. In rats with delayed TB supplementation, EK activity in segment 1 returned almost to control levels at the time of sacrifice. The results confirm the importance of PB secretions in the maintenance of EK activity. The effects of bypass on EK are both enzyme- and site-specific.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramural hematoma of the duodenum

Intramural duodenal hematoma in children is one of the least common injuries encountered. Because of the rarity of this problem, there has been little conformity of opinion as to the relative merits of operative vs nonoperative management. We reviewed 182 cases of this condition, of which 168 were taken from the English literature and 14 from our hospital. Pancreatitis was the most common associated intra-abdominal lesion (21%), while central nervous system, skeletal, and thoracic injuries (5%) accounted for the major extra-abdominal injuries. Hemophilia, von Willebrand's disease, and idiopathic thrombocytopenic purpura occurred in 7 cases and played a major role in the prognosis. Of these cases, 121 patients were treated surgically and 61 conservatively. The average hospitalization was 14 days for the surgical group and 11 days for the conservative group. There were 18 complications in the surgical group. It appears that most patients with intramural duodenal hematoma would respond well to conservative management. Surgery should be reserved for those cases that remain obstructed over seven to ten days or have evidence of perforation.

Intussusception: evolution of current management

The records of 583 children who were treated for intussusception at the Children's Hospital of Buffalo in the period 1930-1985 were reviewed. Following a change in management in 1970 from operative treatment to hydrostatic reduction of the intussusception by barium enema, two main groups are defined. In earlier years 95% of patients underwent operative reduction whereas in the latter period 92% had barium reduction attempted. The remaining 8% in this group had clinical contraindications for hydrostatic enema attempt. Ten percent had pathological lead points. Recurrent intussusception occurred in 50 cases (8.5%), 66% following barium enema reduction and 33% after surgery. The mortality in the earlier group was 3.9% and 1.3% in the latter group. No deaths occurred in patients treated successfully with barium enema reduction, and there were no deaths in the children with simple uncomplicated intussusception requiring surgery.

Lymphoid cell populations in splenectomized and nonsplenectomized SJL/J mice bearing Hodgkin's disease-like reticulum cell sarcoma

Using the reticulum cell sarcoma (RCS) of the SJL/J mouse as a model for Hodgkin's disease, the effects of tumor growth and splenectomy on the T-cell and B-cell populations were evaluated. Although splenectomy improved survival and reduced gross observable tumor growth in secondary tumor sites, no effect on T-cell and B-cell populations was detected. We conclude that tumor growth appears to be undetected by the immune system; previously reported immunosuppression in RCS-bearing mice must be due to functional changes and not cell population changes; and splenectomy contributes to survival and suppression of tumor cell growth in secondary sites.

Advances in the management of infected urachal cysts

Persistent urachal remnants are uncommon congenital anomalies. Unless an umbilical fistula exists, infection may be the first indication of this abnormality. Five children received initial treatment for this problem at the Children's Hospital of Buffalo during a 20-year period, 1964 to 1984, and a sixth was seen secondarily. There were four boys and two girls; their ages ranged from 8 months to 9 years. Lower abdominal mass with fever and local tenderness were the most common presenting signs. Ultrasound was the most accurate study, correctly diagnosing the cyst in both patients so examined. Incision and drainage alone was performed in one patient. The other five were managed with antibiotic therapy and complete excision as the primary procedure. Cultures were obtained in five patients and were positive in four, growing Staphylococcus aureus in three and Escherichia coli in one. Significant genitourinary abnormalities were discovered in four of the five patients evaluated. It is concluded that the previously recommended therapy of incision and drainage followed by delayed resection was developed in the preantibiotic era to minimize the mortality from sepsis and the morbidity from recurrence. Our experience indicates that the use of appropriate antibiotics followed promptly by complete cyst excision as a primary procedure is both possible and safe in most cases. Furthermore, the large number of associated genitourinary abnormalities suggests that a complete work-up for these conditions should be performed.

Percutaneous central venous catheterization in children: first line choice for venous access

Percutaneous central venous (CV) catheters using the jugular and subclavian veins have been widely used for hemodynamic monitoring and for venous access in difficult clinical situations. However, peripheral venous cutdowns (PVC) still remain the primary mode of short-term venous access in children. To evaluate percutaneous CV line insertion as a routine procedure, a prospective study of 115 patients (75 CV and 40 PVC) was performed. Ages ranged from 1 day to 17 years; age and weight were similar in both groups. Eighty-three CV lines were attempted, with a success rate of 93%, while 82% of 49 PVC insertions were successful. Complications occurred in 11 (14%) patients with CV access and 31 (78%) with PVC lines. In the latter group, poor flow was a problem in 65%, infiltration in 37.5%, and phlebitis in 27.5%. In the CV group, arterial puncture occurred during insertion in 2 (3%) patients with no adverse sequelae, catheter slippage occurred in 4 (5%), and poor flow in 2 (3%). A large majority (79.2%) of CV lines functioned successfully until no longer needed, as compared with 15% of PVC catheters. The latter were removed before completion of treatment because of poor flow (40%), phlebitis (20%), or catheter problems (10%). Catheter sepsis was documented in only one CV line. Two cutdowns had major local infections. The average catheter longevity was 10.2 days for CV lines, 4.1 days for PVC.(ABSTRACT TRUNCATED AT 250 WORDS)

Presentation of congenital diaphragmatic hernia past the neonatal period

Congenital diaphragmatic hernias (CDHs) presenting beyond the neonatal period are a rare and unusual problem; they occurred in 11 of 83 children at our institution. Two discrete clinical groups were apparent: (1) younger children, with mainly respiratory symptoms; and (2) older children with gastrointestinal (GI) complaints. Chest roentgenograms suggested CDHs, but GI contrast studies were necessary for confirmation in eight patients. The diagnosis was made preoperatively in ten of 11 children. At operation, no peritoneal sacs were found, the hernial contents were viable in all patients, and malrotation was present in six of 11 patients. None had evidence of pulmonary hypoplasia. Congenital diaphragmatic hernias do present beyond the neonatal age group in a significant number of cases (13% in our series), and a diagnosis of CDH should be considered in any child with persistent GI or respiratory problems and abnormal chest x-ray film findings. The mortality rate in these patients is small, but morbidity may be significant.

The impact of computed tomography scanning on the child with renal trauma

A six-year experience using computed tomography (CT) in the diagnosis of blunt abdominal trauma was reviewed to assess the impact of CT scanning on a patient with renal injury. Three questions were evaluated: Does the increased sensitivity of the CT scan alter the indications for surgery? Does the CT scan help predict the course and eventual outcome of nonoperative therapy? Are there circumstances when the CT scan is not the most efficient and cost effective method of diagnosis? One hundred seventy six consecutive patients with suspected renal trauma were reviewed. One hundred thirty eight were evaluated by CT scan and IVP, the other 38 by excretory urogram alone. Forty four renal injuries were identified. Four of these patients required urgent surgery and four others required later operation for unsuspected congenital anomalies. The injuries sustained by the other 36 cases resolved without surgery. Each patient has been followed for 1 to 5 years following their trauma, and their status assessed by questionnaire and physical examination. The CT technique provides better definition of the injury upon which to base the decision to operate or to enter the patient into nonoperative management. The extravasation seen on CT scan is frequently exaggerated and should not be an absolute indication for exploration. The scan provides improved follow-up data as to completeness of healing and allows directions to be given to the parents concerning resumption of full physical activities. The patients with asymptomatic posttraumatic hematuria, have in our experience, a very low incidence of intraperitoneal or retroperitoneal injuries. Therefore, these patients do not require the advantages of CT scan and may be screened by the less expensive intravenous pyelogram.

The avoidable excesses in the management of perforated appendicitis in children

During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.

Enteral feedback control of pancreatic hypertrophy: the role of pancreatic biliary secretions

Chronic diversion of pancreatic and biliary secretions away from the proximal small intestine resulted in rapid increases in pancreatic size and protein content in adult rats. The effect was detectable as early as 10 days postsurgery. Differential changes in pancreatic enzymes were evident after bypass. The concentration of trypsinogen remained stable while amylase concentrations showed a marked decrease. Total pancreatic trypsinogen content, however, was increased, while amylase content remained similar to controls. Feeding bypassed rats with chows containing various pancreatic and biliary supplements had no effect on the hyperplastic response of their pancreata. Trypsinogen and amylase levels in supplemented groups remained similar to the bypassed group fed nonsupplemented chow, with the exception of increases in trypsinogen concentration and content in the groups supplemented with bile and cotazyme plus bile acids. The adequacy of oral refeeding of pancreatic biliary components was supported by its effectiveness in restoring mucosal enterokinase activity and trypsin levels in segment 1. However, there was no correlation between tryptic activity in the contents of the bypassed segment and the eventual pancreatic weight. These results indicate that factors other than those supplemented in this study are required in maintaining the steady state of pancreatic growth in normal rats.

Present concepts in the treatment of Wilms' tumor

Before 1969, 58 patients with Wilms' tumors treated at Children's Hospital of Buffalo had an all-stage survival of 57%. From 1970 to 1983, following the National Wilms' Tumor Study protocols, this survival rate has improved to 79% in the last 47 patients. With continued attention toward early diagnosis, accurate and complete staging, refinement of radiation and chemotherapy protocols, and absolute follow-up of all patients, the relapse-free survival rate will continue to improve.

Present concepts in the treatment of neuroblastoma

The outlook for the child with neuroblastoma remains dismal. The tumor has been known to undergo spontaneous resolution, and this phenomenon has led to increased interest and research in possible immune mechanisms that may be involved. Treatment often involves the use of surgery, radiation, and chemotherapy, frequently producing a short-term response, but a cure of the disease in an advanced stage can rarely be attributed to any of these treatment modalities. The present staging and treatment method used by the authors is that of the Pediatric Oncology Group (POG) #8104. As far as the immunological therapeutic approach is concerned, promising results have been obtained in animal studies with monoclonal antibodies and immunocellular components. Cumulative data from various pediatric centers have showed that the patient's age strongly influences the prognosis in all stages of the disease.

Advances in the treatment of rhabdomyosarcoma

Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age. Several decades ago it was associated with an 80% mortality rate. Recent advances with combined modality therapy have improved the 5-year survival rate to almost 70%. The focus for the improvement in treatment regimens is now shifting to concerns regarding the preservation of body function and the treatment of far advanced disease. Regardless of age, histology, stage, or site of primary tumor, there has been no group where chemotherapy has not been proven beneficial. The current recommendations used by the Intergroup Rhabdomyosarcoma Study, with regard to chemotherapy, are summarized. Radiation therapy adjunctive to surgery has a useful place in the treatment of rhabdomyosarcoma, but prophylactic nodal irradiation is not recommended. Involved nodes should, however, be treated. Since the potentially adverse side effects of chemotherapy and radiation are accentuated when combined, radiation therapy is no longer recommended in patients with group I rhabdomyosarcoma. Prognostic factors and future considerations from the operative standpoint are presented.

Pancreaticobiliary factors in the modulation of small intestinal enterokinase in the rat

Chronic pancreaticobiliary diversion was employed to study the modulation of enterokinase in the small intestine of adult rats. Diversion resulted in apparent trophic changes of the proximal bypassed portion of the intestinal mucosa. An almost complete loss of mucosal enterokinase activity in the proximal duodenum but no increase of enterokinase in the segments distal to reentry of the common duct was found in the pancreaticobiliary-diverted rats. The effect on the enterokinase activity in the proximal segment was specific in that no other brush-border enzymes measured in that segment were decreased. The decrease in enterokinase was partially prevented by dietary supplementation with pancreatic trypsinogen and completely avoided with the addition of a combination of bile acids and trypsinogen. Supplementation with bile acid alone did not preserve the enterokinase levels in the bypassed rats. The results suggested that trypsinogen is the primary factor responsible for modulating enterokinase levels in the proximal small intestine, with bile acids acting as a modifier.

Wilms' tumor--treatment and results: a five-decade experience

During the past 53 years, 105 patients with Wilms' Tumor have been treated at the Children's Hospital of Buffalo. Prospective and retrospective staging of these cases has allowed comparison with other reported series. All-stage survival improved from 37% with operation alone to 46% with operation and planned radiotherapy. During the past 22 years, with the addition of adjunctive chemotherapy, all-stage survival is now 80% with lesser stage survival approaching 100%. Participation in the cooperative National Wilms' Tumor Study has brought the most effective proven treatment to the patient in the shortest period of time.

Prosthetic materials and muscle flaps in the repair of extensive diaphragmatic defects: an experimental study

Relative merits of three methods of diaphragmatic hernia repair were evaluated in growing animals. Twenty-five puppies underwent laparotomy. In four controls, the left hemidiaphragm was incised and sutured primarily. In the remaining dogs, it was partially resected sparing the phrenic nerve. The defects were repaired in six with silastic sheeting, in eight with polytetrafluoroethylene (PTFE; trademark, Gore-Tex), and in seven with a thoracoabdominal muscle flap. Dogs were killed at 1, 4, and 7 months for gross and microscopic evaluation of the repair. Diaphragmatic function was evaluated by inspiratory force against a closed airway and by selective phrenic nerve stimulation (PNS). Serial fluoroscopy was used to evaluate diaphragmatic motion. Grossly the diaphragms in all groups showed compensatory growth. Microscopically the silastic was encapsulated without adherence, while PTFE showed tissue ingrowth. Maximal inspiratory force was equivalent in all groups but selective PNS revealed left-sided impairment in all experimental groups. Fluoroscopy showed paradoxical motion of the diaphragm in the muscle flap group for 1 to 2 months, and in the silastic repair group for 2 to 3 weeks, with near normal motion in the PTFE group for the entire postoperative period. These differences disappeared by 6 months. Prosthetic materials or muscle flaps are all safe for repair of large diaphragmatic hernias. Diaphragmatic growth occurs and the prosthesis remains in place. Physiologic impairment is minimal and not of clinical importance. Use of PTFE may be the preferred method as it develops better tissue incorporation and results in more normal diaphragmatic motion in the critical early postoperative period.

The effect of the immunomodulator corynebacterium parvum on hemisplenectomized mice

The immunomodulator Corynebacterium parvum stimulates the reticuloendothelial system and causes splenic hypertrophy. The ability of C parvum to stimulate splenic regeneration in hemisplenectomized mice and decrease susceptibility to intranasal pneumococcal challenge was studied. Mice were divided into two groups, control sham-operated (n = 48) and hemisplenectomized (n = 47) animals. Ten days later, each group was divided into two subgroups, those injected with C parvum (700 mcg IVP) and those injected with an equivalent volume of saline. The animals were challenged with Streptococcus pneumoniae, which was injected into one nostril three weeks postoperatively, and mortality was assessed. Four and one-half weeks postoperatively, splenic tissue was removed, measured, weighed, and submitted for histologic examination. The number of spleen cells per gram of tissue was assessed. Treatment with C parvum resulted in a significant increase in the splenic weight in both hemisplenectomized and control animals compared to similar saline-injected mice (P less than 0.001). The percentage increase in spleen weight of hemisplenectomized mice (106%) was significantly greater than that for control animals (56%; P less than 0.01). There was no significant difference among experimental groups in the number of spleen cells per gram of splenic tissue or in the histologic characteristics, indicating that C parvum stimulated relatively normal splenic growth. Survival following pneumococcal challenge was significantly increased for hemisplenectomized mice by C parvum treatment to a level that did not significantly differ from control mice. This study demonstrates that in mice the deficits related to resistance to infection and spleen size following hemisplenectomy are significantly improved by treatment with C parvum.

The intercostal vein: an alternate route for central venous alimentation

During the course of parenteral nutrition in infants, access to the central venous system may become limited due to thrombotic occlusion of the superior and inferior caval venous systems. When this problem arises, central venous access via the intercostal vein into the azygos system can provide a safe, relatively easy solution. A new technique utilizing this approach has been developed at our institution using silicone elastomer tubing joined with a Broviac catheter for long-term use. Thus far, six catheters have successfully been inserted with a mean duration of 52 days; one catheter was in place for as long as 110 days.

Treatment of defects of the anterior abdominal wall in newborns

Primary closure of an omphalocele or gastroschisis may cause respiratory compromise in the neonate. Some authors recommend primary closure of the defect with prolonged respiratory support because of dissatisfaction with staged visceral reduction and use of a Silastic pouch. Our experience with use of a Silastic pouch from 1975 to 1982 was reviewed. Twenty-three newborns with major defects of the abdominal wall (14 omphaloceles and 9 gastroschisis anomalies) were surgically treated, and only one death occurred. The mean birth weight of the infants was 2,927 g; nine of them were premature. Seven infants had major associated anomalies. The goal of the surgical procedure was closure of the abdominal wall without compromise of the cardiorespiratory status. During the operation, muscle relaxants were avoided and the infants breathed spontaneously. If progressive visceral reduction caused tachypnea (rate of more than 70/min) or hemodynamic instability, a Silastic pouch was constructed. Ten patients were treated with primary fascial closure, and 13 were treated with a Silastic prosthesis. The neonates with the prostheses required three to eight reductions, and the prostheses were in place for 4 to 22 days. No patient had wound dehiscence, wound infection, or an intestinal fistula. The one death occurred in an infant with trisomy 18 syndrome and multiple anomalies. Thus, the Silastic pouch was effective when the defect could not be closed primarily without respiratory compromise.

The nonoperative management of pediatric hepatic trauma

Although nonoperative therapy is well-accepted for renal and splenic injuries in children, this mode of treatment has not been widely advocated for children with blunt hepatic injury. Surgical repair or excision of the traumatized tissue has been the generally accepted standard of care. In the present series, 17 consecutive children between 2 and 13 years of age with liver trauma were managed by nonoperative means. Patients were carefully selected for treatment based on clinical criteria and initial computed tomography (CT) scan findings. The 17 patients with hepatic trauma identified by CT scan all responded to initial resuscitative measures. The children clinically remained stable and required only a limited number of transfusions. No immediate surgical intervention was necessary for isolated hepatic injuries. However, one patient required exploration due to an associated renal pedicle avulsion. One child required exploration on the fourth post-injury day because of a suspected infected hematoma. The remaining 15 injuries resolved without operation. Healing was documented on follow-up CT scans. The mean time required for resolution of the injury was 4 months. One child developed a late subhepatic hematoma which resolved without drainage. The progression of healing of hepatic parenchymal injuries was observed by serial CT scans. The liver injury progressed through stages of coalescence, resorption, and remodeling prior to final healing. Utilizing proper patient selection, many blunt liver injuries can be managed nonoperatively.

Chronic relapsing pancreatitis in childhood caused by pancreaticobiliary ductal anomaly

Chronic relapsing pancreatitis is a rare childhood disease. Although various obstructive phenomena have been implicated in its etiology, few reports have described the role played by anomalies of the pancreaticobiliary ductal system. Recently, a patient with a complex anomalous ductal communication was treated by us for chronic relapsing pancreatitis. This particular anomaly, and its clinical presentation, has not previously appeared in the literature. The problems associated with the diagnosis and surgical management of this patient have prompted this report.

A long-term follow-up on a duplication of the entire small intestine treated by gastroduplication

Duplication of the entire small intestine resulting in gastrointestinal hemorrhage was managed by excision of the ulcerogenic lesion, ileo-ileostomy, and diversion of the gastric-lined intestinal duplication into the stomach. A 25 yr followup study reveals no evidence of recurrent bleeding or malabsorption secondary to bind-loop syndrome. This operative procedure is worthy of consideration in patients with this congenital anomaly.

The use of different induction and maintenance chemotherapy regimens for the treatment of advanced yolk sac tumors

Four children with yolk sac tumor were treated with an aggressive combination chemotherapy program. Three children had presacral primary tumors, one having pulmonary metastases, and one had a testicular primary tumor with pulmonary metastases. Three children were treated when they had measurable disease, and one had no measurable disease. The chemotherapy program consisted of a 6-wk induction period with vincristine (VCR), cis-diamminedichloroplatinum (DDP), and bleomycin. Maintenance therapy consisted of VCR, actinomycin D, and cyclophosphamide (cytoxan) every 3-4 wk as tolerated. Treatment was discontinued after 12 mo of complete remission. All three patients with evaluable disease had a partial response (PR) to induction therapy. Two underwent surgical exploration following induction therapy, one a laparotomy and the other a thoracotomy, and were found to have only scar tissue at the sites of presumed residual disease. The third child with measurable disease progressed to a clinical complete response (CR) during maintenance therapy. Two patients have had no evidence of disease (NED) for 42+ and 41+ mo since starting therapy (28+ and 27+ mo since completing treatment). Two patients are NED 11+ and 7+ mo since starting therapy and remain on treatment. We have encountered no significant renal or pulmonary toxicity, and there have been only two hospitalizations during maintenance therapy for fever and neutropenia. These preliminary results employing different induction and maintenance chemotherapy programs and planned second-look surgical intervention appear encouraging.