Laparoscopic and robotic pyeloplasty as minimally invasive alternatives to the open approach for the treatment of uretero-pelvic junction obstruction in infants: a multi-institutional comparison of outcomes and learning curves.

BACKGROUND: Since the development of minimally invasive surgery (MIS), laparoscopic and robotic approaches have been widely adopted. However, little has been published detailing the learning curve of MIS, especially in infants. OBJECTIVE: To quantify the learning curve of laparoscopic (LP) and robot-assisted laparoscopic pyeloplasty (RAL-P) for treatment of uretero-pelvic junction obstruction (UPJO) in infants evidenced by number of cases, operative time, success and complications. PATIENTS AND METHODS: Between 2009 and 2017, we retrospectively reviewed pyeloplasty cases for treatment of UPJO in infants at three academic institutions. The primary outcome was success. Secondary outcomes were UPJO recurrence, complications, and operative time as a surrogate of skill acquisition. Continuous variables were analyzed by t test, Welch-test, and one-way ANOVA. Non-continuous variables were analyzed by Chi-squared test or Fisher's exact test. Learning curves (LC) were studied by r-to-z transformation and CUSUM. RESULTS: Thirty-nine OP, 26 LP, and 39 RAL-P had mean operative times (OT) of 106, 121, and 151 min, respectively. LCs showed plateau in OT after 18 and 13 cases for LP and RAL-P, respectively. RAL-P showed a second phase of further improvements after 37 cases. At 16 months follow-up, there were similar rates of success and complications between the three groups. CONCLUSIONS: Despite different duration of learning phases, proficiency was achieved in both LP and RAL-P as evidenced by stabilization of operative time and similar success rates and complications to OP. Before and after achievement of proficiency, LP and RAL-P can be safely learned and implemented for treatment of UPJO in infants.

Do adult patients with congenital colorectal conditions know their diagnosis?

PURPOSE: Limited research exists about the knowledge that adult patients have about their congenital colorectal diagnosis. METHODS: This was an IRB approved, prospective study of patients in the Adult Colorectal Research Registry who completed surveys between October 2019 and March 2022. Surveys were administered through REDCap after patients consented to being contacted for research purposes. Patients provided demographic data, which was linked to surgical records, and the diagnoses provided by patients were compared with diagnoses recorded by the original surgeons. RESULTS: One hundred and thirty-one questionnaires were collected, 115 patients had anorectal malformations (ARM) and 16 had Hirschsprung disease (HD). Seven patients who had ARM were unaware that they had an ARM or HD. The type of ARM recorded by the surgeon was unavailable for comparison with the patient's reported diagnosis in four cases. Of the 111 remaining patients with ARM, only 32 of them (29%) knew what their own type of anomaly was. Female patients recalled their diagnosis more often than male patients (42.4% vs 13.5%). All 16 participants with HD correctly identified their diagnosis severity as HD with or without total colonic aganglionosis. CONCLUSION: The results of this study demonstrate patient's limited understanding of their type of ARM and highlight the urgent need to enhance communication and education strategies, such as issuing patients with medical diagnosis identification cards. It is critical for clinicians to better communicate with patients to ensure that they and their relatives truly understand their precise diagnosis. Adequately informed patients can better advocate for themselves, adhere to treatments and precautionary recommendations and navigate the complexities of transitional care. Consequently they can more effectively manage their lifelong complications.

Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children. OBJECTIVE: The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls. STUDY DESIGN: Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery. RESULTS: A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations. DISCUSSION: Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding. CONCLUSION: ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.

Genitourinary and gastrointestinal co-morbidities in children: The role of neural circuits in regulation of visceral function.

OBJECTIVE: Pediatric lower urinary tract dysfunction (LUTD) is a common problem in childhood. Lower urinary tract symptoms in children include overactive bladder, voiding postponement, stress incontinence, giggle incontinence, and dysfunctional voiding. Gastrointestinal co-morbidities, including constipation or fecal incontinence, are commonly associated with lower urinary tract (LUT) symptoms in children, often reaching 22-34%. This review summarized the potential mechanisms underlying functional lower urinary and gastrointestinal co-morbidities in children. It also covered the current understanding of clinical pathophysiology in the pediatric population, anatomy and embryological development of the pelvic organs, role of developing neural circuits in regulation of functional co-morbidities, and relevant translational animal models. MATERIALS AND METHODS: This was a non-systematic review of the published literature, which summarized the available clinical and translational studies on functional urologic and gastrointestinal co-morbidities in children, as well as neural mechanisms underlying pelvic organ 'cross-talk' and 'cross-sensitization'. RESULTS: Co-morbidity of pediatric lower urinary and gastrointestinal dysfunctions could be explained by multiple factors, including a shared developmental origin, close anatomical proximity, and pelvic organ 'cross-talk'. Daily physiological activity and viscero-visceral reflexes between the lower gastrointestinal and urinary tracts are controlled by both autonomic and central nervous systems, suggesting the dominant modulatory role of the neural pathways. Recent studies have provided evidence that altered sensation in the bladder and dysfunctional voiding can be triggered by pathological changes in neighboring pelvic organs due to a phenomenon known as pelvic organ 'cross-sensitization'. Cross-sensitization between pelvic organs is thought to be mainly coordinated by convergent neurons that receive dual afferent inputs from discrete pelvic organs. Investigation of functional changes in nerve fibers and neurons sets certain limits in conducting appropriate research in humans, making the use of animal models necessary to uncover the underlying mechanisms and for the development of novel therapeutic approaches for long-term symptomatic treatment of LUTD in the pediatric population. CONCLUSION: Pediatric LUTD is often complicated by gastrointestinal co-morbidities; however, the mechanisms linking bladder and bowel dysfunctions are not well understood. Clinical studies have suggested that therapeutic modulation of one system may improve the other system's function. To better manage children with LUTD, the interplay between the two systems, and how co-morbid GI and voiding dysfunctions can be more specifically targeted in pediatric clinics need to be understood.

Systematic review of bladder cancer outcomes in patients with spina bifida.

BACKGROUND: In patients with congenital bladder anomalies, bladder augmentation is used as a last resort to reduce intravesical pressure, but concerns about malignant transformation in augmented patients were first raised in the 1980s. The best evidence to date indicates that augmentation does not appear to increase the risk of bladder cancer in spina bifida patients. To date, oncologic outcomes from patients with spina bifida with and without augmentation have only been available in small case reports. OBJECTIVE: To systematically evaluate factors in myelomeningocele patients with bladder cancer, including bladder augmentation, that contribute to overall survival (OS). STUDY DESIGN: A systematic review using PubMed was conducted by cross referencing terms 'myelomeningocele,' 'cystoplasty,' 'bladder cancer' and respective synonyms according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were studies with patients with an underlying diagnosis of myelomeningocele and bladder cancer with data on age, stage, and mortality status. Studies were excluded for spinal cord injury, history of tuberculosis or schistosomiasis, or prior ureterosigmoidostomy. RESULTS: Fifty-two patients were identified from 28 studies with a median age at bladder cancer diagnosis of 41 years (range 13-73); 37 (71%) presented with stage III or IV bladder cancer. Overall survival at 1 year and 2 years was 48.5% and 31.5%, respectively. Overall survival was different between those with and without augmentation (P = 0.009) by log-rank analysis. No between-group differences in OS were seen based on age, management with indwelling catheter, diversion with ileal conduit or being on a surveillance program. Only stage remained a significant predictor of OS on multivariate analysis (HR 2.011, 95% CI 1.063-3.804, P = 0.032). Secondary analysis was performed after removing patients with gastric augmentation (n = 8), and no difference in OS was seen between patients with (n = 8) and without augmentation (n = 36, P = 0.112). Of augmented patients, latency to development of bladder cancer was variable (Summary Figure). DISCUSSION: Bladder cancer is a deadly diagnosis in patients with congenital bladder anomalies like spina bifida, and while overall prevalence of the two conditions occurring together is low, bladder cancer will go on to affect 2-4% of spina bifida patients. The present study examined overall survival, and further characterized outcomes in these patients. Presence of a bladder augment did not appear to worsen overall survival. CONCLUSIONS: Patients with myelomeningocele who developed bladder cancer had aggressive disease. Augmentation did not worsen OS, based on cases reported in the literature. Risk of bladder cancer should be discussed with all myelomeningocele patients.

Study of clitoral hood anatomy in the pediatric population.

INTRODUCTION AND AIMS: Pediatric female genitalia size and morphology have not previously been well described. The aims of this study were to create a standard reference for the anterior vulval structures, and examine the relationship between the clitoral hood and labia minora. METHOD: Female patients between 0 and 16 years of age, and with normal external genitalia had the following measurements taken: length of clitoral hood, length of sides of clitoral hood, clitoral diameter, apex of clitoral hood to base of pubic symphysis, apex of clitoral hood to urethral orifice, distance of clitoral hood to labia majora, and length and depth of labia minora. Qualitative descriptors of the clitoral hood and labia were recorded. Patients were grouped into age ranges for analysis: 0-3 years, 4-8 years, 9-12 years, and 13-16 years. RESULTS: Fifty-eight girls were examined. There was a linear relationship between age and genital structure size. In the majority of patients, the labia minora converged under the clitoral glans, separate to the clitoral hood. Four shapes of clitoral hood were observed: horseshoe, trumpet, coffee bean, and tent. DISCUSSION: This study observed great variation in size and morphology of pediatric female genitalia, which is in keeping with other studies. The study was limited by ability to recruit older patients to the study (girls aged 11-16 years) and, therefore, there were lower numbers in this age category. However, the trends that were observed were present in both younger and older girls. CONCLUSION: External genitalia size and morphology are varied in the pediatric female population. The clitoral hood and labia minora were observed to be distinctly separate structures. This study provides a reference for surgeons undertaking genital reconstruction procedures. The study demonstrated that the clitoral hood and labia minora are anatomically distinct structures.

Inter-rater reliability of postnatal ultrasound interpretation in infants with congenital hydronephrosis.

PURPOSE: The most common measurements of hydronephrosis are the anterior-posterior (AP) diameter and the Society for Fetal Urology (SFU) grading systems. To date, the inter-rater reliability (IRR) of these measures has not been compared in the postnatal period. The objectives of this study were to compare the IRR of the AP diameter and the SFU grading system in infants and to determine whether ultrasound findings other than pelvicalyceal dilation are associated with higher SFU grades. METHODS: Initial postnatal ultrasounds of infants seen from February 1, 2011, to January 31, 2012, with a primary diagnosis of congenital hydronephrosis were included for review. Ultrasound images were de-identified and reviewed by four pediatric urologists. IRR was calculated using the intraclass correlation (ICC) measure. A paired t test was used to compare ICCs. Associations between SFU grade and other ultrasound findings were tested using Chi-square or Fisher's exact tests. RESULTS: A total of 112 kidneys in 56 patients were reviewed. IRR of the SFU grading system was high (right kidney ICC = 0.83, left kidney ICC = 0.85); however, IRR of AP diameter measurement was higher (right kidney ICC = 00.97, left kidney ICC = 0.98; p < 0.001). Renal asymmetry (p < 0.001), echogenicity (p < 0.001), and parenchymal thinning (p < 0.001) were significantly associated with SFU grade 4 hydronephrosis on bivariable and multivariable analysis. CONCLUSIONS: The SFU grading system is associated with excellent IRR, although the AP diameter appears to have higher IRR. Physicians may consider ultrasound findings that are not explicitly included in the SFU system when assigning hydronephrosis grade, which may lead to variability in use of this classification system.

Continuous local anesthetic infusion for children with spina bifida undergoing major reconstruction of the lower urinary tract.

OBJECTIVE: While many options for postoperative analgesia are available to the general patient population, choices are limited for individuals with spinal dysraphism. We hypothesized that the use of continuous local anesthetic infusion following major reconstruction of the lower urinary tract in children with spina bifida would significantly decrease need for opiate use, while maintaining adequate pain control. MATERIALS AND METHODS: Children with spina bifida who underwent major reconstruction of the lower urinary tract at Children's Hospital Colorado were identified from January, 2003 through January, 2013 were identified. In addition to enterocycstoplasty, procedures included Mitrofanoff or Monti creation, bladder neck reconstruction, and Malone antegrade continence enema. Patients who had local anesthetic infusion catheters placed in the incision were compared to patients without catheters. Opioid consumption was calculated by conversion of any opiates into IV morphine (mg/kg) on postoperative days (POD) 0-3. Pain was assessed by mean and maximum FLACC scores on POD 0-2. Use of antiemetic medications and wound related complications were recorded as secondary metrics. Patients with other etiologies for neurogenic bladder and bowel were excluded. Patients whose pain was assessed by other assessment scales were excluded. Chi-squared analysis was used for nominal variables, students t-test was used for analysis of continuous variables. P values <0.05 were considered significant. RESULTS: 36 myelomeningocele patients who underwent primary enterocystoplasty met the inclusion criteria. All surgeries were open procedures. 24 patients in the infusion catheter group were compared to 12 patients who received primary analgesia by PCA or IV narcotics. There were no significant differences in age, sex, weight or spinal defect level between the two groups. Opioid use, as defined by IV morphine equivalents, was significantly less in the wound soaker group on all PODs. The total opioid use after POD #0-3 was 0.55 mg/kg in the wound soaker group vs 1.66 mg/kg in the IV/PCA group (p = 0.03). FLACC scores were uniformly lower in the wound soaker group, but were not significantly different. There was a significant decrease in need for postoperative antiemetic use in the wound soaker group (36.5% vs 83.3%, p = 0.014). Complications and hospital stay were similar between both groups. DISCUSSION: The advantage of local anesthesia is the reduction of systemic opioids and their subsequent adverse side effects. Our results suggest that in children with spina bifida undergoing major reconstruction of the lower urinary tract narcotic consumption is approximately 1/3 when continuous local anesthetic catheters are placed into the incision. The need for antiemetic medication is also significantly less. While this technique has been validated in a variety of other settings, it may be most beneficial in patients with myelomeningocele or other spinal dysraphism where epidural placement is generally contraindicated and narcotic use may have a particularly deleterious effect on preexisting neurogenic bowel function. The primary limitation of our study is that it is a retrospective review of a limited number of patients. Patients were not randomized and subject to other management differences that could have influenced our results in unknown ways. CONCLUSIONS: Continuous local anesthetic catheters are a simple, effective alternative strategy to provide postoperative analgesia while reducing systemic opiate use and associated adverse effects.

Abdominal sensitivity in the first year of life: comparison of infants with and without prenatally diagnosed unilateral hydronephrosis.

There are few studies on visceral pain in infants, despite its clinical importance. We have used the abdominal skin reflex (ASR) to measure changes in abdominal sensitivity in the presence of visceral pathology in infants. The reflex was elicited by applying calibrated von Frey hairs to each side of the abdomen and the mechanical threshold and the degree of reflex radiation as denoted by hip flexion were measured. The developmental progression of ASR properties during the first year of life was studied in a cross-sectional sample of healthy infants ranging from 30 to 95 weeks postconceptional age (PCA). These properties were compared to those in infants with unilateral hydronephrosis (UH) using a blinded protocol. Infants with UH were studied at their first outpatient appointment after birth, and postoperatively following surgery if this was indicated. The investigators were blinded to laterality and severity of hydronephrosis until data were analysed, or until surgery. A total of 30 patients with UH and 77 healthy infants were included in the study. In 21 (70%) patients, the side of hydronephrosis had a significantly lower ASR threshold than the contralateral side of the abdomen. There was a significant increase in reflex threshold and decrease in reflex radiation with increasing PCA in control infants. However, in UH infants, this relationship did not exist, even on the unaffected side of the abdomen.Our results show that infants with prenatally diagnosed UH demonstrate increased abdominal sensitivity compared with control infants. Using the ASR, we have provided the first evidence of referred visceral hypersensitivity in infants.

Cell biology of bladder development and the role of the extracellular matrix.

The bladder is unique. It is the most distensible organ in the body. If the normal pattern of development is disturbed, the bladder can become dysfunctional and poorly compliant. Renal outcome is intimately linked to bladder function and hence bladder development. In this review we describe our current knowledge of the molecular processes that govern bladder development, with particular emphasis on the role of the extracellular matrix. Finally, we suggest a hypothetical model for bladder development.

Antenatal diagnosis of pediatric surgical anomalies. Counseling the family.

Improvements in screening and diagnostic techniques now mean that hundreds of congenital anomalies can be antenatally diagnosed. It is, however, impossible and inappropriate to submit all pregnant women to a barrage of investigations. Screening is necessary before specific invasive investigations are initiated. These include history, physical examination, MS-AFP screening, estriol and hCG screening, and a Level II ultrasonography scan. Once at-risk pregnancies have been identified, a multidisciplinary team approach is commenced and further studies including Level II ultrasonography, amniocentesis, chorionic villus sampling, or cordocentesis can be performed so that an accurate diagnosis is available. Counseling of the parents throughout is essential so that appropriate decisions regarding this and further pregnancies can be made.

Prenatal diagnosis of congenital diaphragmatic hernia with predictors of mortality.

Since the late 1970s, congenital diaphragmatic hernia (CDH) has been diagnosed antenatally by ultrasound. With improvements in ultrasound resolution, CDH is being diagnosed more frequently and at an earlier stage in gestation. This provides an opportunity to administer in utero therapy to the fetus. As 50% of babies born with CDH survive, it is imperative that accurate prognostic indicators are available to guide antenatal therapy. Antenatal diagnosis and prognostic indicators are discussed.

Pulmonary parenchymal abnormalities in congenital diaphragmatic hernia.

Congenital diaphragmatic hernia results in abnormal lung development. There is a global hypoplasia with both lungs affected, the ipsilateral lung more severely. This results in a reduction in the number of bronchial divisions and a decrease in the quantity and maturity of the alveoli. The pneumocytes are dysfunctional, resulting in a total quantitative and qualitative reduction in surfactant and a decrease in antioxidant enzyme activity.

Animal models in congenital diaphragmatic hernia.

The first animal model of congenital diaphragmatic hernia (CDH) was described in 1967. This was a late-gestational, surgically-created lamb model. Since then, animal modeling has become more sophisticated. Using a variety of techniques and laboratory species, animal models have been produced to investigate the pathophysiology of CDH, from whole animal physiology studies to lung molecular changes. To provide the animal tissue required, three different approaches have been used: (1) a surgically-created model which has been reported in lambs and rabbits, (2) a teratogen-induced model which to date has been described in rats and mice, and (3) a congenital model which is present in a specific pig herd. All animal models are discussed in this article.

The Malone (antegrade colonic enema) procedure: early experience.

PURPOSE: The aim of this study was to assess the results of the Malone (antegrade colonic enema) procedure for fecal incontinence. METHODS: By a retrospective review of patients treated between 1990 and 1996 in a tertiary referral center, 36 patients were treated with a Malone procedure. Age at operation was 8.3 (range, 3 to 14) years, the mean period of follow-up was 39 (range, 9 to 72) months. The indication was fecal soiling in 35 and chronic constipation in one. The underlying diagnosis was an anorectal anomaly in the majority of patients. The appendix was used in 30 patients and a cecal flap in six, and a submucosal antireflux procedure was also performed in 10. In 35 patients, a circular stoma was created and in one a V flap was used. Antegrade colonic enemas were performed daily in 10, alternate days in 23, and in three patients the stoma was no longer used. Enemas were performed with a 10F catheter using a mixture of phosphate enema (or liquorice) and saline. RESULTS: Fecal soiling was completely controlled in 28 patients, and eight children soiled more than once a week. Complications occurred in 15 patients; the main problem was stenosis of the conduit, which occurred in 9 of 30 appendiceal stomas and three of six cecal stomas. Stomal stenosis was treated with surgical revision in eight patients. Additional complications were reflux through the stoma (n=2), pain on catheterisation (n=1), and small bowel obstruction (n=1). In one patient the Malone has been converted to a colostomy. CONCLUSIONS: The Malone procedure is a simple technique that can effectively control fecal incontinence in the majority of cases. It appeared to be better in older children. Stomal stenosis is a frequently encountered problem that may require surgical revision.

Repeat pull-through for Hirschsprung's disease.

BACKGROUND: A repeat pull-through for Hirschsprung's disease is undertaken when the original procedure has failed. The reasons for failure include a retained aganglionic segment, stricture, fistula, or persisting incontinence. METHODS: All patients who underwent a redo pull-through from 1982 through 1996 were included. Twenty-two patients were underwent surgery; 20 notes were reviewed. The mean age at operation was 6 years (range, 1 to 13). Mean time between operations was 5.1 years (range, 0.5 to 13). RESULTS: Postoperative complications occurred in five patients. These included wound infection, recurrent rectal septum, division of a vas, compartment syndrome, and an anastomotic stricture. Follow-up was for 6.5 years (range, 0.2 to 12). The mean number of bowel movements was 2.2 per day (range, 1 to 6). Fourteen (of 19) patients were continent or soiling less than once per week. Soiling occurred more than once a week in four, but two of these were incontinent after the first operation. One has a colostomy. CONCLUSION: A repeat pull-through is a worthwhile procedure when dealing with an anatomic problem such as retained Hirschsprung's disease, stenosis, or fistula.

Gastrojejunal fistula after insertion of percutaneous endoscopic gastrostomy.

The authors report the case of a 12-year-old boy with cystic fibrosis, in whom a percutaneous endoscopic gastrostomy device migrated into the jejunum, forming a gastrojejunal fistula.

One-stage neonatal pull-through to treat Hirschsprung's disease.

INTRODUCTION: Traditionally Hirschsprung's disease has been treated by a three-stage procedure. This approach has been associated with stoma problems, three episodes of hospitalization, and a theoretical disadvantage, because of the delayed passage of feces via the rectum, in controlling defecation. The aim of this study was to assess the results of one-stage neonatal pull-through for the treatment of Hirschsprung's disease. METHODS: This was a 10-year retrospective review of all patients treated with a neonatal pull-through for Hirschsprung's disease. Information was obtained from the patients' records. All descriptive data are expressed as mean +/- standard deviation. RESULTS: Fifty-one patients were treated in the 10-year period studied. The mean gestational age was 39.6 +/- 1.7 weeks, weight was 3.3 +/- 0.54 kg, with 76% being boys. The surgery was performed at 10.3 +/- 5.8 days of age. A Swenson procedure was carried out in 38 patients and a Soave in 13. The extent of the disease was rectosigmoid in 39, and the remaining were sigmoid, descending colon, and total colonic. The mean length of the surgery was 181 +/- 40 minutes. Blood transfusions were required in 13 patients with a mean volume of 55 mL given. The complications observed were: an anastomotic leak in two cases, requiring laparotomy and colostomy (both in patients with Down's syndrome), and wound infection in three cases. There were two delayed deaths both associated with other congenital anomalies. In total, three patients required further surgery; two had colostomies, one requiring a redo pull-through and one had an ileostomy for enterocolitis. The total length of hospital stay was 20.4 +/- 11.2 days. Mean follow-up was 3.73 +/- 2.9 years. In 21 patients the follow-up was greater than 4 years and in this group none were totally incontinent. Four patients complained of soiling at least once a week, and 17 had normal bowel control. CONCLUSION: Hirschsprung's disease can be successfully treated in the neonatal period with a one-stage pull-through. The short- and long-term results are as good as those with the three-stage procedure, with the child usually benefitting by not having a stoma and a shorter hospital stay.

Toothbrush ingestion by bulimics may require laparotomy.

Two girls accidentally swallowed their toothbrush while inducing emesis; both had bulimia. Early removal of the brush is advised to prevent complications. Endoscopic removal is the preferred method, but because of the toothbrush's geometric qualities, surgical retrieval is often required.

Neurovascular morbidity from the lithotomy position.

The lithotomy position is used in pediatric surgery when it is necessary to have simultaneous access to the abdomen and perineum. At the authors' institution, after a prolonged period in the lithotomy position, significant lower limb complications developed in four patients. Two patients with Hirschsprung's disease underwent a redo Duhamel procedure, one had an anorectal leiomyoma excised, and one had an ileoanal anastomosis for ulcerative colitis. Sciatic nerve injury developed in two patients and deep venous thrombosis and bilateral compartment syndrome resulting in myonecrosis developed in one each. There is an association between operations that require prolonged lithotomy position and the development of postoperative neurovascular complications. By placing the child in the lithotomy position only when access to the perineum is required, these significant injuries may be avoided.