AIMIn contrast to other countries, no collective study of Rehbein's procedure in German-speaking nations has been performed. Therefore, our intention was, analogously to Goto and Ikeda's (10) Japanese study in 1984, Kleinhaus's (13) study on Swenson's procedure in 1979, Bourdelat's (2) French-Canadian investigation into Duhamel's technique in 1997 and Martuciello's (11) and Teitelbaum's (16) follow-up in the year 2000, to perform a follow-up study of Rehbein's technique of deep anterior resection.METHODSThe data of 200 patients from 22 German-speaking centers in Switzerland, Austria and Germany were collected. These data were gathered by questionnaire and the children were followed up in the individual participating hospitals for at least 3.5 years after the procedure. The procedure was performed between 1993 and 1997, over a 5-year period. The questionnaire contained 74 items including anamnestic data, diagnostic postoperative treatment and reoperations.RESULTSConcerning the incidence of anastomotic leaks and resolving anastomotic strictures there was no significant difference between the results in our series and those of the collective analyses made by Hofmann von Kap-herr (7), Holschneider (9) and Sherman (18). In 6.6 % of the 191 patients an anastomotic leak and in 9.9 % a rectal stricture, which had to be dilated, was observed. Concerning late complications, 22.8 % of the children suffered from constipation, 4.3 % from encopresis, 10.6 % from enterocolitis and only 0.5 % from enuresis. The frequency of constipation diminishes over the years. A comparison of the different large series in the literature clearly shows that the incidence of constipation is higher after Rehbein's procedure and the frequency of urinary incontinence and encopresis higher following Swenson's, Soave's and Duhamel's techniques. The incidence of enterocolitis is less after Rehbein's procedure than after Swenson's, Soave's and Duhamel's techniques.CONCLUSIONSThe different results in the literature are due to the individual experience of the author, the very different follow-up methods and the date of follow-up. Therefore, the different results are hard to compare with our study. Nevertheless, Rehbein's anterior resection still could be presented as an adequate and important method to treat Hirschsprung's disease.

Zusammenfassung Hintergrund: Die ultraschallgesteuerte hydrostatische Reposition einer intestinalen Invagination ermöglicht im Unterschied zu anderen Therapiekonzepten eine Reposition ohne Strahlenbelastung. Gezeigt werden sollte, daß dieses Verfahren gleichwertige Erfolge bietet. Methode: Alle Invaginationen, diagnostiziert an der Kinderklinik der TU München von 1989–1999, wurden retrospektiv analysiert und durch Zusammenstellung der wichtigsten Veröffentlichungen die verschiedenen Therapiekonzepte verglichen. Ergebnisse: Von 158 Invaginationen (Alter der Patienten: 2–130 Monate) lösten sich 10 spontan, 9 mußten primär operiert werden. 87,1% aller Repositionsversuche führten zum Erfolg, bei Berücksichtigung nur der ileokolischen Invaginationen sogar 95,1%. Die Erfolgsrate betrug bei Rezidivinvaginationen 79% bei einer Häufigkeit von 9,5%. Komplikationen traten selten auf: Letalität 0%, Perforationsrate 0,7%. Diese Resultate entsprechen den Ergebnissen der ultraschallgesteuerten hydrostatischen Reposition in der Literatur. Schlußfolgerung: Die ultraschallkontrollierte hydrostatische Reposition bietet neben der höheren Erfolgsrate und der niedrigeren Rate an Komplikationen im Vergleich zu allen anderen Therapiekonzepten weitere Vorteile. Daher sollte dieses Verfahren bevorzugt werden, zumal mit der Farbdopplersonografie eine neue Möglichkeit der nichtinvasiven Durchblutungskontrolle als prognostischer Parameter besteht.

Zusammenfassung Fragestellung: Es soll geklärt werden, inwieweit ein präoperatives EKG bei Kindern für die Risikoabschätzung vor einer Narkose notwendig ist. Methode: Wir überprüften die Narkoseprotokolle von 3030 Kindern, bei denen im Jahr 1990 in unserer Klinik eine Narkose durchgeführt wurde, und stellten die Komplikationen bei diesen Narkosen den Ergebnissen der präoperativen EKGs gegenüber. Außerdem werteten wir Fragebögen zu diesem Thema aus, die wir 1991 an 51 große Kinderkliniken in Deutschland verschickt haben. Ergebnisse: Bei 3030 Narkosen traten 93 Komplikationen auf, von denen 67 nicht kardial bedingt waren. Von den 26 kardialen Komplikationen waren nur 4 behandlungsbedürftig (AV-Block 2°, Blutdruckabfall, Schock). Von 180 präoperativ geschriebenen EKG waren 152 normal; 8 zeigten harmlose Normvarianten, 16 wurden wegen bekannter Herzfehler durchgeführt. Keines dieser Kinder hatte Komplikationen bei der Narkose. Die Fragebögen wurden von 36 der 51 angeschriebenen Kinderkliniken sorgfältig ausgefüllt zurückgeschickt. In den meisten Kliniken wird nur bei Hinweisen auf eine mögliche oder bestehende Herzerkrankung ein präoperatives EKG geschrieben. Schlußfolgerung: Es gibt bei Kindern keine Indikation für ein präoperatives EKG als Routinemaßnahme. Nur wenn sich aus Anamnese und körperlicher Untersuchung Hinweise auf eine Herzerkrankung ergeben, ist ein EKG und – bei Bedarf auch ein Echokardiogramm – eine sinnvolle Untersuchung.

Objective:The aim of this study is to examine whether a routine preoperative ECG is necessary in children to assess the risks in anaesthesia and surgery.Methods: We examined the records of 3030 children anaesthetized in our hospital in 1990 and compared records of complications with preoperative ECGs. We also evaluated questionnaires on this subject which we had sent to 51 large pediatric hospitals in Germany in 1991.Results: During 3030 anaesthetic procedures there were 93 complications, 67 of which were not of cardiac origin. Of the 26 cardiac complications only 4 needed therapy (AV-Block 2 degrees, fall in blood pressure). Preoperative ECGs were recorded in 180 cases: 152 were normal,8 showed harmless deviations from normal and 16 were recorded because of known cardiac defects. None of the 180 children developed complications during anaesthesia. Our questionnaire was returned completed carefully by 36 of the 51 hospitals. ln most hospitals a preoperative ECG is only recorded when heart disease is known or suspected.Conclusion: Routine preoperative ECGs are unnecessary in children unless there are clinical symptoms of heart disease or heart disease is suspected.

From 1989 to 1995 high-resolution ultrasonography (US) was performed in 3,546 children (age: 1-17 years) with clinically suspected appendicitis. A total of 518 patients underwent laparotomy; 420 had histologically proven acute or perforated appendicitis (prevalence 11.8 %). In these children, the sensitivity, specificity and overall accuracy of US examination were 90 %, 97 % and 96 % respectively. The use of US in clinically doubtful acute abdomen may allow earlier diagnosis of acute appendicitis; in 1995 the rate of unnecessary appendectomy was reduced to 13 %.

In childhood blunt trauma to the chest wall is more frequent than penetrating injuries. Most of these are the result of traffic accidents. Solitary or serial rib fractures are seen more often than fractures of the sternum. Complications of thoracic injuries are pulmonary contusion, hemothorax and, less frequently, pneumothorax. Pulmonary contusion can result in post-traumatic pneumatocele or chronic pulmonary hematoma. Injuries of the heart, the great vessels and bronchotracheal rupture, presenting initially with pneumothorax, followed by atelectasis, rarely occur. Blunt thoracic trauma is frequently associated with further injuries (head and/or blunt abdominal trauma). The prognosis also depends on the concurrent injuries. The initial evaluation of an injured child is based on the chest X-ray and abdominal ultrasound examination. Additional information can be obtained by a CT scan in mediastinal injuries.

In childhood blunt trauma to the chest wall is more frequent than penetrating injuries. Most of these are the result of traffic accidents. Solitary or serial rib fractures are seen more often than fractures of the sternum. Complications of thoracic injuries are pulmonary contusion, hemothorax and, less frequently, pneumothorax. Pulmonary contusion can result in post-traumatic pneumatocele or chronic pulmonary hematoma. Injuries of the heart, the great vessels and bronchotracheal rupture, presenting initially with pneumothorax, followed by atelectasis, rarely occur. Blunt thoracic trauma is frequently associated with further injuries (head and/or blunt abdominal trauma). The prognosis also depends on the concurrent injuries. The initial evaluation of an injured child is based on the chest X-ray and abdominal ultrasound examination. Additional information can be obtained by a CT scan in mediastinal injuries.

ACTH-independent Cushing's syndrome is either due to an adrenal tumor or to bilateral primary pigmented nodular adrenocortical dysplasia (PPNAD). The first category requires unilateral, and the latter bilateral adrenalectomy. We are reporting a 5 m old girl with ACTH-independent UMAH, clinically and historically distinct from PPNAD. who was cured by unilateral adrenalectomy. Our patient developed obesity, a moon face, and growth arrest within the first 2 m of life. There were no other features suggestive of the "Carney complex". At 4 m of age, serum cortisol at 8, 12, 21, and 24 h was 76.8, 73.1, 115, and 84.4 μg/dl. non-suppressible by dexamethasone (2 and 8 mg/1.7 m2). and ACTH was undetectable (before and after CRF). Ultrasound and NMR showed a multinodular enlarged right and a normal left adrenal A right-sided adrenalectomy and a biopsy of the left adrenal revealed both diffuse and nodular cortical hyperplasia without internodular atrophy and with preservation of the fetal cortex in the right adrenal, and normal macro- and microscopic morphology in the contralateral gland, both features being clearly distinct from classical PPNAD. Surgery resulted in clinical and biochemical cure, and 5 m later, the hypothalamo-pituitary-adrenal axis was still partially suppressed, necessitating low-dose hydrocortisone replacement. On the basis of the unilateral process documented both morphologically and biochemically, and the specific histology of the diseased adrenal, we suggest that 1) UMAH in infancy is a separate entity distinct from PPNAD, and 2) the treatment of choice consists of unilateral adrenalectomy.

Aus einem Patientengut von 87 Kindern mit Steißbeinteratomen innerhalb von 25 Jahren aus drei kinderchirurgischen Kliniken mit insgesamt 73 Überlebenden wurden 52 Patienten nachuntersucht. Als Spätergebnisse wurden die Resultate von 35 Kindern bewertet, bei denen die Operation länger als drei Jahre zurücklag. Aus dieser Gruppe wurden 18 Kinder nur klinisch nachuntersucht, ohne daß funktioneile Beeinträchtigungen festgestellt werden konnten. Durch den zusätzlichen Einsatz der Elektromanometrie von Blase und Enddarm wurden bei weiteren 17 Kindern aus dieser Gruppe jedoch in etwa 40 % Störungen der Blasen- und Mastdarmfunktion aufgedeckt, die teils myogener, teils neurogener Natur waren und eine direkte Beziehung zu der Größe, der Dignität und der intrapelvinen Ausbreitung des Steißbeinteratoms zeigten.

52 patients were followed up out of a total of 87 children with sacrococcygeal teratomas, within a period of 25 years, from three paediatric surgery hospitals and out of altogether 73 survivors. The results in 35 children where the operation had been performed more than three years ago, were classified as "late results". From this group, 18 children were followed up by clinical examination only, without detecting any dysfunctions. By the additional use of electromanometry of urinary bladder and rectum, however, bladder and rectum dysfunctions were seen in about 40% of 17 further children. These dysfunctions were partly myogenic and partly neurogenic in nature and were directly related to the size, tumour status and intrapelvic extension of the sacrococcygeal teratoma.