Neonatal renal tumors are very rare. We have identified 15 cases of Wilm's tumors diagnosed in the first 30 days of life. The most common presentation was an abdominal mass on routine newborn examination, and three tumors were noted on an antenatal ultrasound. All of the infants underwent primary excision of the tumor. Five infants were not given postoperative chemotherapy after surgical excision. One of these children had a relapse and later died of progressive disease. The remaining children are alive at a median follow-up of 31 months. Eight of the tumors had evidence of nephrogenic rests. More frequent follow-up physical and imaging examinations are indicated in children not given adjuvant chemotherapy or whose tumors show nephrogenic rests.

To determine whether the current “gatekeeper” controls on health care lead to an increase in treatment delay and morbidity of acute appendicitis in children, we reviewed the experience with this disease at a large children's hospital over a 10-year period. One hundred seven consecutive children 18 years and younger operated on for acute appendicitis from July 1, 1988 to June 30, 1990 were compared with 119 children with the same diagnosis from July 1, 1978 to June 30, 1980. Age, sex, race, antecedent illnesses, initial physician contact and diagnosis, time to referral and operation, pathology, morbidity, and length of stay were reviewed. The two groups were comparable in terms of age, sex, race, antecedent illnesses, and negative appendectomy rate. More patients in the recent group were initially seen in an emergency room or urgent care setting than in the previous group (62.2% v 48.5%, P = .07). The accuracy of the initial diagnosis was significantly lower in the more recent group (P = .05). No change existed between the groups in the time to a physician; however, a significant (P = .04) difference existed in the time to surgeon (41.2 hours in the earlier group v 56.4 hours in the recent group). No significant difference existed between the groups in time from surgeon to operation. Although not statistically significant, the morbidity rate was increased in the recent group (13.3% v 6.5%, P = .17). However, more complex morbidity occurred in the recent group, including 6 patients with 2 or more complications, and 2 deaths, compared with one patient with multiple complications and no deaths in the earlier group. Factors affecting the presence of complications include time to physician, time to surgeon, and pathology (multiple logistic regression). No significant difference existed in length of stay between the groups. In the interval of 10 years at a children's hospital, it now takes more time for patients with acute appendicitis to reach the pediatric surgeon, with a subsequent trend toward more frequent and complex morbidity. Factors in the present health care environment to account for these findings include changes in the initial physician-contact setting, greater misdiagnosis, and delayed surgical referral. Greater physician and public education is necessary to deter these trends.

Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA The pediatric general surgery patient represents a wide variety of disease processes and organ systems. This review discusses the purpose of intensive care units and a philosophy for establishing admission guidelines for the pediatric intensive care unit. The multiply injured child is the most frequent pediatric intensive care unit admission from a pediatric surgery service. Additionally, certain elective cases will predictably require admission, especially those involving the airway or major blood loss, latrogenic disease accounts for about 5% of pediatric intensive care unit admissions. The pediatric intensive care unit exists to care for patients who need respiratory support, are hemodynamically unstable, or require intensive monitoring or treatment that cannot be provided elsewhere.

We evaluated a myo-osseous intercostal pedicle flap for distal tracheal reconstruction. Mongrel puppies, 6 to 10 weeks old, underwent tracheal repair, 12 for primary defects and seven for stenotic lesions created in the distal trachea. A composite flap was constructed from the anterior portion of the fourth rib with the overlying pleura and periosteum and a posteriorly based intercostal muscle/neurovascular pedicle. The animals did well following tracheal reconstruction without evidence of airway obstruction. Bronchoscopy documented normal tracheal diameter and the repair site could not be discerned from the surrounding mucosa. Histologically, there was complete respiratory epithelial ingrowth with no inflammatory changes. The rib graft had active hematopoietic marrow. This work suggests that the myo-osseous intercostal pedicle flap provides a surface for normal epithelial ingrowth of tracheal mucosa without stimulating granulation tissue, interposes a stent capable of growth, therefore minimizing anastomotic stricture, and is an effective alternative in the management of distal tracheal stenosis.

In Reply .—Our article on acalculous cholecystitis in the neonate 1 was intended to alert the reader to the problem. The scant number of cases reported was hardly sufficient to make solid recommendations about definitive management. In our current era of intensive care, acute acalculous cholecystitis is becoming a recognized cause of sepsis in the severely stressed patient. (I have operated on two premature infants with gangrenous gallbladders.) The infant described in our report 1 was recovering, but we were quite concerned that we were dealing with a choledochal cyst. We were quite surprised intraoperatively to find the resolving cholecystitis. The abnormal histology of the specimen was striking. Dr Coulter raises several good points, and we appreciate his instruction on the issue of right upper quadrant abdominal masses in the premature infant. I would like to assure him that we neither recommend nor perform cholecystectomy in every newborn with an

Gastroesophageal reflux (GER) in the pediatric patient is a frequently recognized problem. Unlike the adult, in whom symptoms relating to esophagitis predominate, the infant and child may present with a variety of respiratory problems, vomiting and/or growth failure. GER is often seen in association with other conditions and must be considered in the evaluation of any pediatric patient with chronic recurring respiratory problems, vomiting or failure to thrive (FTT). Thirty-eight pediatric patients have been surgically managed at West Virginia University from 1977-1983 for GER. The patients fall into several different patterns of presentation and associated problems. Nine premature infants all with bronchopulmonary dysplasia (BPD) have undergone fundoplication for FTT, worsening BPD, and pneumonia. Seven infants and two older children had GER associated with previous esophageal atresia repairs. Esophagitis, vomiting and growth failure were the predominant complaints in this group, though all nine patients had recurring respiratory symptoms as well. Syndromes involving mental retardation and neurologic dysfunction affected another group of five patients, all of whom presented with the complications of long-term esophagitis. The remaining 15 children were otherwise healthy infants who had predominantly respiratory symptoms due to GER. The benefits of fundoplication in these severely affected infants and children far outweigh the relatively few complications. In the carefully selected patient, surgical management of GER is dramatically successful.

Total colectomy with ileoproctostomy was performed in 32 members of a family spanning three generations and ranging in age from 10 to 54 years. In seven of these patients (22 percent) carcinoma developed in the retained rectum over a median follow-up period of 14 years. This high incidence of rectal carcinoma has demanded reevaluation of treatment recommendations in patients with polyposis coli. Ten patients aged 7 to 30 years have undergone total abdominal colectomy with ileoanal endorectal pull-through since 1980. All were one stage procedures without reservoir construction. Within 3 months the patients all had good control with 5 to 10 semiformed stools daily and had resumed normal activities. Follow-up date shows adequate dilatation of the distal ileum and no evidence of polyps. Total colectomy and ileoanal endorectal pull-through are effective treatment for familial polyposis in patients of all ages. It should be considered the primary procedure in new patients and an excellent method of converting those patients who have ileoproctostomy to a safer situation.

This is a case report of a patient treated at West Virginia University Medical Center that illustrates the successful use of preoperative percutaneous angiographic embolization of a pheochromocytoma in controlling a malignant hypertensive crisis.

Intercostal muscle pedicle flaps have been successfully utilized in the treatment of recurrent tracheoesophageal fistulae and esophageal perforations in the pediatric age group. An intercostal myo-osseous pedicle flap was also created to repair a distal congenital tracheal stenosis at the carina. The viable intercostal flap has the advantage of multiplicity of uses and of considerable mobility. The presence of a blood supply assures healing. The option of retaining periosteum on the flap encourages bone regeneration at the site of tracheal or bronchial repair. The pleura of the flap provides an epithelial surface for intratracheal repair. The rib graft prevents stricture at the site of tracheal repair.

Eighteen of the patients randomized for treatment according to the first and second National Wilms' Tumor Studies have developed clinically evident tumor in the contralateral kidney subsequent to the initial diagnosis. Only seven of 18 had an adequate exploration of the opposite kidney during the initial surgery and of these seven, four had abnormal findings. Thirteen of 18 cases showed some form of nephroblastomatosis histologically. The original tumors in six and possibly seven were multicentric in origin. While metachronous Wilms' tumors are an unusual occurrence, the prognosis is ominous with only seven of 18 surviving free of disease. The outlook might be improved with adequate attention to the surgical and histologic details during the initial diagnostic procedures.

Twenty-eight cases of gastroschisis have been treated over a five-year period. Twenty-two silos were placed and 19 infants had uncomplicated silo closure. Enlargement of the abdominal wall defect to allow optimum reduction of the edematous bowel was essential to closure in less than a week. Rapid removal of the prosthesis and strict adherence to aseptic technique prevented septic complications. Inability to return the bowel to the abdominal cavity within five to six days mandated re-exploration to determine the cause for failure to reduce the silo. Accordingly, three infants were re-explored. Two patients had unrecognized intestinal lesions and a third infant, whose defect had not been enlarged, had infarction of the midgut. Six infants underwent primary closure; two with preinatal evisceration and four who had concomminant cutaneous enterostomies performed for intestinal atresia. Intestinal atresia or stenosis occurred in 25% of these infants. Postoperative management was facilitated by insertion of a gastrostomy tube, early peripheral venous nutrition and later insertion of a central venous catheter for nutrition. The one postoperative death (3.5% mortality rate) resulted from failure to follow the principles of silo management as outlined in this report.

Fistulous communications between the esophagus and tracheobronchial tree as a consequence of lye ingestion are very rare and may occur as a direct result of the caustic, or later, after dilatation of a resulting stricture.1