Changing relationship of pediatric surgical workforce to patient demographics.

BACKGROUND: Physician workforce studies indicate that more specialists contribute to higher average costs. The closely monitored pediatric surgery specialty may reflect what is occurring in other specialties. METHODS: This report reviews the number of complex operations performed on infants and children in 1970, with <225 trained US pediatric surgeons, and in 2010, when there were 1,130. The number of births remained consistent during this 40-year period. RESULTS: In 2010, approximately 10,710 complex index operations were performed on children in the United States by certified pediatric surgeons, resulting in 9.5 per surgeon annually. Data from the University of California, Los Angeles, and the Vanderbilt Children's Hospital confirm these observations. CONCLUSIONS: The progressive disparity in the number of pediatric surgeons trained and the number of complex index operations performed annually may increase costs and calls into question the ability of individual pediatric surgeons to maintain optimal competence. Consideration might be given to performing index operations at centers of excellence.

Cardiovascular magnetic resonance in patients with pectus excavatum compared with normal controls.

PURPOSE: To assess cardiothoracic structure and function in patients with pectus excavatum compared with control subjects using cardiovascular magnetic resonance imaging (CMR). METHOD: Thirty patients with pectus excavatum deformity (23 men, 7 women, age range: 14-67 years) underwent CMR using 1.5-Tesla scanner (Siemens) and were compared to 25 healthy controls (18 men, 7 women, age range 18-50 years). The CMR protocol included cardiac cine images, pulmonary artery flow quantification, time resolved 3D contrast enhanced MR angiography (CEMRA) and high spatial resolution CEMRA. Chest wall indices including maximum transverse diameter, pectus index (PI), and chest-flatness were measured in all subjects. Left and right ventricular ejection fractions (LVEF, RVEF), ventricular long and short dimensions (LD, SD), mid-ventricle myocardial shortening, pulmonary-systemic circulation time, and pulmonary artery flow were quantified. RESULTS: In patients with pectus excavatum, the pectus index was 9.3 ± 5.0 versus 2.8 ± 0.4 in controls (P < 0.001). No significant differences between pectus excavatum patients and controls were found in LV ejection fraction, LV myocardial shortening, pulmonary-systemic circulation time or pulmonary flow indices. In pectus excavatum, resting RV ejection fraction was reduced (53.9 ± 9.6 versus 60.5 ± 9.5; P = 0.013), RVSD was reduced (P < 0.05) both at end diastole and systole, RVLD was increased at end diastole (P < 0.05) reflecting geometric distortion of the RV due to sternal compression. CONCLUSION: Depression of the sternum in pectus excavatum patients distorts RV geometry. Resting RVEF was reduced by 6% of the control value, suggesting that these geometrical changes may influence myocardial performance. Resting LV function, pulmonary circulation times and pulmonary vascular anatomy and perfusion indices were no different to controls.

912 open pectus excavatum repairs: changing trends, lessons learned: one surgeon's experience.

BACKGROUND: Severe pectus excavatum (PE) is common, often causing physiologic impairment. Inconsistent results have been reported using a variety of open surgical techniques with extensive subperiosteal costal cartilage resection. METHODS: Since 1969, 912 (80% men) symptomatic PE patients (mean severity index 4.9) underwent open surgical correction at UCLA Medical Center by one surgeon. Almost all patients had dyspnea, reduced endurance, tachypnea, and tachycardia with exertion. The mean age at operation was 19.8 years. Asymmetric depression was present in 465 (51%) patients; combined PE and pectus carinatum was present in 33 patients. Recurrent PE deformities were repaired on 73 patients. Progressively less deformed costal cartilage was resected during the 38-year period; almost all of the last 303 patients had only short segments excised from both ends with suture reattachment. Transverse wedge sternal osteotomy was used on all patients, and 883 (97%) had a sternal support strut for 6 to 9 months. RESULTS: Dyspnea, endurance, tachypnea, and tachycardia was improved in almost all patients within 5 months after repair. Repair for recurrent deformities and resection of mild localized cartilage protrusion was reduced more than threefold when minimal cartilage resection with wire reattachment was used. Postoperative complications in the last 537 patients were less frequent, pain was less severe, and results were better than when more extensive previous repairs were used (mean follow-up 7.6 years). Very good or excellent results were reported by 94.2% of all patients. CONCLUSIONS: In this largest series of open PE repair, progressively less extensive operative techniques have resulted in low morbidity, mild pain, short hospitalization, and very good physiologic and cosmetic results.

Surgical correction of pectus carinatum: lessons learned from 260 patients.

BACKGROUND: Patients with pectus carinatum (PC) frequently experience physiologic symptoms, which are often overlooked by physicians. Sparse data have been published regarding the indications for correction of PC and the newer techniques of surgical repair. METHODS: Since 1970, 260 (89% males) symptomatic patients with PC with a mean severity index of 1.81 underwent open surgical correction at the University of California, Los Angeles, Medical Center by 1 surgeon. All patients had experienced dyspnea, reduced endurance, and tachypnea with exertion. Asthmatic symptoms were noted by 22%. The mean age at operation was 18.2 years. Asymmetric protrusion was present in 126 (48%) patients. Combined protrusion of the upper chest and depression of the lower chest was present in 17 patients. Varying degrees of depression on one or both sides of the lower chest was present in 36%. Repair of recurrent PC deformities was performed on 16 patients. Progressively, less costal cartilage was resected over the 37-year period, with the last 181 patients having only short segments excised from both ends of deformed cartilages with suture reattachment. Transverse sternal osteotomy was used on all, and 242 (93%) had a support strut anterior to the sternum for 6 months. RESULTS: Exercise induced dyspnea, and reduced endurance was improved in all patients within 3 to 6 months after repair. Need for repair of recurrent deformities and resection of mild residual cartilage protrusion was reduced more than 3-fold when less extensive cartilage resection with wire reattachment was used. Postoperative complications in the last 181 patients were minor and less frequent, pain was less severe, hospitalization was shorter (mean, 2.6 days), and postoperative results were better than when more extensive repairs were used in previous years. With a mean overall follow-up of 6.2 years, 97.4% of all patients reported a very good or excellent result. CONCLUSIONS: In this largest reported series of PC repair, progressively less extensive open techniques have resulted in low morbidity, mild pain, short hospital stay, and very good physiologic and cosmetic results.

Repair of pectus chest deformities in 320 adult patients: 21 year experience.

BACKGROUND: Severe pectus chest deformities are common, often causing physiologic impairment. Patients who do not undergo repair during childhood often experience progressive worsening of symptoms during adulthood. There are few published reports regarding pectus repair in adults. METHODS: A retrospective review from January 1986 through January 2007 was performed on patients age 19 years and older, who underwent surgical correction of pectus excavatum (PE) or carinatum (PC) at one hospital. RESULTS: Adult patients, including 268 PE (84%), 41 PC (13%), and 11 with combined deformities (3%) underwent open repair with minimal cartilage resection and a temporary internal support strut. Ages ranged from 19 to 67 years (mean, 27). Patients experienced dyspnea, decreased endurance and tachypnea with mild exertion (99%), tachycardia (94%), and chest pain (69%). All patients reported worsening of symptoms during adolescence, which became more severe during adulthood. The mean severity score for PC and PE was 1.8 and 5.8, respectively (normal = 2.5). All patients experienced improvement in symptoms within four months after repair. Mean hospitalization was 2.9 days. Complications included pleural effusion (n = 8), pneumothorax (n = 4), and pericarditis (n = 2). Small localized protrusions persisted in eight patients. Four patients underwent repair of mild recurrent deformities. There were no deaths. Ninety-eight percent reported considerable improvement in exercise tolerance and indicated postoperative results as very good or excellent. CONCLUSIONS: Uncorrected pectus deformities persist after childhood and often cause worsening symptoms with increasing age. Repair can be performed in adults with low morbidity, short hospital stay, and considerable improvement in physiologic function.

Recent experience with open repair of pectus excavatum with minimal cartilage resection.

HYPOTHESIS: Inconsistent results have been reported using a variety of open surgical techniques to correct pectus excavatum (PE) deformities with subperiosteal resection of deformed costal cartilages. DESIGN: Retrospective 6-year review of 450 consecutive patients undergoing PE repair. SETTING: Tertiary care academic medical center. PATIENTS: Symptomatic patients with severe PE (severity index >3.4). INTERVENTION: Evaluation of open repair with minimal cartilage resection, suture reattachment of costal cartilages to the sternum and ribs, and internal support strut for 6 months. MAIN OUTCOME MEASURES: Age at repair, severity index, reduction of symptoms, complications, recurrence, and mortality. RESULTS: Nine percent of patients were younger than 12 years at repair, 42% were aged 12 to 17 years, 33% were aged 18 to 30 years, and 16% were older than 30 years. Nineteen percent were female. Mean +/- SD severity index was 4.88 +/- 1.8. Mean hospital stay was 2.9 days. No patients received epidural analgesics. Complications occurred in 2.6% of patients and included idiopathic ventricular arrhythmia (2 patients), transient pericarditis (2 patients), pleural effusion (3 patients), dislodged sternal bar (2 patients), hematoma (1 patient), seroma (1 patient), and localized infection (1 patient). Mild recurrence occurred in 4 patients, and 9 patients had resection of localized cartilage protrusion when the bar was removed. There were no deaths. Ninety-eight percent of patients reported very good to excellent results. All patients reported improvement in symptoms. Mean follow-up was 26 months after strut removal. CONCLUSION: In this largest, to our knowledge, recently reported series of openly repaired PE using minimal cartilage resection and suture reattachment of the costal cartilages to the sternum and ribs, advantages included short operative time, stable early postoperative chest wall, few complications, mild pain, good physiologic and cosmetic results, and effectiveness for all variations of PE in patients of all ages.

Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection.

BACKGROUND: Numerous modifications of the Ravitch open repair of pectus excavatum (PE) and carinatum (PC) have been used by surgeons with inconsistent results. METHODS: During a 3-year period, 275 consecutive patients underwent open repair of PE and PC using a new less invasive technique. A small chip of costal cartilage was resected medially and laterally from each deformed cartilage, allowing it to barely touch the sternum and rib (laterally) after the sternum had been elevated or depressed, and twisted to the desired position. A support strut used for all patients was routinely removed within 6 months. RESULTS: With mean follow-up of 17 months, all but 5 patients regarded the results as very good or excellent. There were no major complications or deaths. CONCLUSION: Open repair using minimal cartilage resection is effective for all variations of PE and PC in patients of all ages, causes only mild pain, and produces good physiologic and cosmetic results.

Open repair of pectus excavatum with minimal cartilage resection.

OBJECTIVE: To summarize the clinical experience with a new open repair for pectus excavatum (PE), with minimal cartilage resection. SUMMARY BACKGROUND DATA: A wide variety of modified techniques of the Ravitch repair for PE have been used over the past 5 decades, with the complications and results being inconsistent. Extensive subperiosteal costal cartilage resection and perichondrial sheath detachment from the sternum may not be necessary for optimal repair. METHODS: During a 12-month period, 75 consecutive patients with symptomatic PE underwent open repair using a new less invasive technique. After exposing the deformed costal cartilages, a short chip was resected medially adjacent to the sternum and laterally at the level where the chest had a near normal contour, allowing the cartilage to be elevated to the desired level with minimal force. A transverse anterior sternal osteotomy was used on most patients. A substernal support strut was used for 66 patients; the strut was placed anterior to the sternum in 9 patients under age 12 and over age 40 years. The strut was routinely removed within 6 months. RESULTS: With a mean follow-up of 8.2 months, all but 1 patient regarded the results as very good or excellent. Mean operating time was 174 minutes; mean hospitalization was 2.7 days. There were no major complications or deaths. CONCLUSIONS: The open repair using minimal cartilage resection is effective for all variations of PE in patients of all ages, uses short operating time, provides a stable early postoperative chest wall, causes only mild postoperative pain, and produces good physiologic and cosmetic results.

Less extensive techniques for repair of pectus carinatum: the undertreated chest deformity.

BACKGROUND: Although patients with pectus carinatum (PC) often experience moderate to severe symptoms, there are sparse published data about the indications for correction, the newer techniques of surgical repair, and the results. This study reviews clinical experience with new, less extensive, open operative techniques for repair of PC. STUDY DESIGN: Since 1970, 154 patients (119 men and 35 women) with symptomatic PC (mean severity index 1.76) underwent correction at the UCLA Medical Center using modifications of the Ravitch repair. The last 60 consecutive patients had a less extensive open repair with resection of only small chips of cartilage medially and laterally, and suture reattachment of the remaining costal cartilages to the corrected sternum and ribs. For patients with chondromanubrial protrusion, two or three sternal osteotomies were used, and for those with concomitant lower sternal depression, a lower sternal wedge osteotomy was used. For most patients, a temporary support bar anterior to the sternum and cartilages was used for 6 months. RESULTS: Each of the 154 patients with reduced endurance or dyspnea with mild exercise experienced marked improvement within 6 months. There were no major recurrent deformities; six patients underwent minor surgical revision of localized persistent costal cartilage protrusion or depression. Postoperative complications in the last 60 patients were minor and less frequent, pain was less severe, hospitalization was shorter (mean 2.5 days), and postoperative results were better than when more extensive repairs were used in previous years. With a mean overall followup of 7.9 years, more than 97% of all patients experienced a very good or excellent result. CONCLUSIONS: New, less extensive, open techniques for repair of PC have low morbidity, short hospital stay, and very good physiologic and cosmetic results.

Management of pectus chest deformities in female patients.

BACKGROUND: There is sparse published information regarding surgical management of females with pectus excavatum (PE) or carinatum (PC) deformities. METHODS: During the past 33 years 104 females with PE, and 21 with PC underwent surgical repair using extensive modifications of the Ravitch technique. Seven had previous right breast implants, 3 had prostheses placed in the PE deformity. Nine PE patients underwent successful pregnancy before repair, but had severe third trimester dyspnea. RESULTS: Very good to excellent results were reported by 96% (mean follow-up, 6 years). Increased endurance, decreased dyspnea, reduced chest discomfort, and less tachycardia occurred in all within 6 months. No patients had significant breast asymmetry after repair. Complications included mildly hypertrophic scar (8), transient pleural effusion (3), bar displacement (1), and mild recurrence (3). CONCLUSIONS: Females with symptomatic PE or PC, can be repaired with low morbidity, mild pain, low cost, and improvement in body image and symptoms. Prostheses are not beneficial in the treatment of physiologic symptoms caused by pectus deformities.

Mucosal regeneration of a duodenal defect using small intestine submucosa.

Intestinal tissue engineering has the potential of developing new treatment strategies for patients with a deficit in intestinal surface area. The purpose of this study was to investigate the capacity of small intestine submucosa (SIS) to regenerate intestinal epithelia in a rodent model for a duodenal defect. A duodenotomy was created in 20 Sprague-Dawley rats and was repaired with a circular patch of SIS. The repaired sites were retrieved 1, 2, 4, and 12 weeks after implantation. The size of the residual mucosal defect was measured. The retrieved tissues were fixed in formalin and processed by standard histologic techniques. The animals tolerated the procedure well. The mean size of the mucosal defects significantly decreased with time. Complete epithelialization of the defects was noted within 4 weeks in three of five samples. Histologically, the defects were lined with crypts and villi, but the muscularis layer did not regenerate. In the rodent model, SIS can be used as a patch to repair a duodenotomy. Mucosal regeneration was observed in the area of the defect. Further studies will determine whether SIS may be used to preserve or increase mucosal surface area in patients whose bowel length is compromised.

Cardiorespiratory outcome after corrective surgery for pectus excavatum: a case study.

PURPOSE: The purpose of this case study was to examine the effect of pectus excavatum before and after surgical correction on ventilatory and cardiorespiratory responses to submaximal and maximal exercise. METHODS: The patient was a 30-yr-old longshoreman who had mild pectus excavatum since infancy that became worse during his adolescent growth years. The deformity persisted into adulthood with increasing symptoms. Although he had a history of habitual aerobic exercise, the patient experienced frequent episodes of pain in the lower anterior chest, breathlessness, and reduced stamina when performing activities of daily living. He performed pulmonary function tests, submaximal and maximal incremental exercise testing, before and 6 months after corrective surgery. RESULTS: Six months after corrective surgery, the patient demonstrated increases in FEV1 (13.0%), maximum voluntary ventilation (MVV, 32.3%), maximum power output (max, 15.5%), [OV0312]O2max (7.9%), metabolic threshold ([OV0312]O2theta, 30.8%), oxygen-pulse ([OV0312]O2/fc, 14.0%), and maximal tidal volume (VTmax, 11.7%). On submaximal testing, we found that the time constant for oxygen uptake kinetics was 46.8 s for the on-transit and 46.5 s for the off-transit before surgery and 33.6 s for the on-transit and 30.3 s for the off-transit six months after surgery. CONCLUSIONS: The information derived from this case study supports the opinion that corrective surgery for pectus excavatum may alleviate the impaired ventilatory and cardiorespiratory performance seen preoperatively.

Ventilatory and cardiovascular responses to exercise in patients with pectus excavatum.

PURPOSE: Uncertainty exists as to whether pectus excavatum causes true physiologic impairments to exercise performance as opposed to lack of fitness due to reluctance to exercise. The purpose of this study was to examine the effect of pectus excavatum on ventilatory and cardiovascular responses to incremental exercise in physically active patients. METHODS: Twenty-one patients with pectus excavatum (age range, 13 to 50 years; mean [+/- SD] age, 23.6 +/- 8.9 years; severity index range, 3.7 to 8.0; mean severity index, 5.1 +/- 1.2) were referred for preoperative evaluation. Eighteen of the patients (85%) had a history of performing aerobic activity ranging from 30 min to 2 h per day (mean duration, 1.0 +/- 0.61 h per day) for 3 +/- 1.5 days per week. Patients performed pulmonary function tests, and submaximal and maximal incremental exercise testing. RESULTS: On maximal exercise testing, the maximum oxygen uptake (O(2)max), and oxygen-pulse were significantly lower than the reference values (t(20) = 6.17 [p < 0.0001] and t(20) = 4.52 [p < 0.0001], respectively). Furthermore, patients exhibited cardiovascular limitation, but not ventilatory limitation. Despite their high level of habitual exercise activity, the overall metabolic threshold for lactate accumulation was abnormally low (ie, 41% of the reference value for O(2)max) especially in those with a pectus severity index (PSI) of > 4.0 (39% of the reference value of O(2)max), which is consistent with cardiovascular impairment rather than physical deconditioning. Patients with a PSI of > 4.0 were also eight times more likely to have reduced aerobic capacity than patients who had a low severity index, despite their level of exercise participation. On submaximal testing, we found that the time constant for O(2) uptake kinetics was 37.4 s for the on-transit and 41.6 s for the off-transit. The observed values for FVC, FEV(1), maximum voluntary ventilation, and diffusing capacity of the lung for carbon monoxide were significantly lower than reference values, but those for total lung capacity and residual volume were not significantly lower than reference values. CONCLUSIONS: The information derived from this study supports the opinion that pectus excavatum is associated with true physiologic impairment and reduced exercise capacity, predominantly due to impaired cardiovascular performance rather than ventilatory limitation. Furthermore, the impairment is not explained by physical deconditioning.

Surgisis patch tracheoplasty in a rodent model for tracheal stenosis.

BACKGROUND: Tracheal stenosis is a challenging surgical problem that can require reconstruction using autologous grafts or artificial stents. In this study, we evaluate the efficacy of Surgisis, a commercially available, biocompatible, acellular matrix, in the repair of a critical-size tracheal defect. METHODS: A full-thickness defect (2 mm x 6 mm) was created in tracheal rings 4 through 6 in adult rats. A piece of 8-ply Surgisis (Cook; Bloomington, IN) was sutured to the edges of the defect with interrupted 8-0 polypropylene sutures. In control animals, the defect was closed primarily. The trachea was harvested at 4 weeks and prepared for histologic evaluation using conventional techniques. Cross-sectional area and perimeters were calculated using imaging software. RESULTS: Tracheal defects without patch repair (n = 3) resulted in tracheal stenosis and immediate death. Animals that underwent Surgisis patch repair of tracheal defects (n = 10) tolerated the procedure well and had no audible stridor or evidence of respiratory distress. Eight of ten animals survived 4 weeks. The tracheal lumen was patent with no evidence of contracture or degradation of the Surgisis. Histologically, neovascularization of the Surgisis was noted with moderate inflammation. The surface of the Surgisis patch was covered ith a lining of ciliated epithelial cells. CONCLUSION: In the rodent model, Surgisis appears to be an efficacious method for the patch repair of partial circumferential tracheal defects. Surgisis appears to be a safe and promising means of facilitating neovascularization and tissue regeneration. The long-term use of Surgisis warrants further investigation.

Current management of pectus excavatum.

Pectus excavatum (PE) is one of the most common anomalies of childhood. It occurs in approximately 1 in every 400 births, with males afflicted 5 times more often than females. PE is usually recognized in infancy, becomes much more severe during adolescent growth years, and remains constant throughout adult life. Symptoms are infrequent during early childhood, but become increasingly severe during adolescent years with easy fatigability, dyspnea with mild exertion, decreased endurance, pain in the anterior chest, and tachycardia. The heart is deviated into the left chest to varying degrees causing reduction in stroke volume and cardiac output. Pulmonary expansion is confined, causing a restrictive defect. Repair is recommended for patients who are symptomatic and who have a markedly elevated pectus severity index as determined by chest X-ray or computed tomography scan. Repair using the highly modified Ravitch technique is usually performed after the age of 8 years. The optimal age for repair is between 12 and 16 years. Repair can be performed on adults with similar good results. Recent modifications in the Ravitch technique remove minimal cartilage and routinely use a temporary internal support bar for 6 months. Operation rarely takes more than 3 hours, and hospitalization rarely exceeds 3 days. Pain is mild and complications are rare, with 97% of patients experiencing a good to excellent result. The new minimally invasive Nuss repair avoids cartilage resection and takes less operating time, but is associated with more severe pain, longer hospitalization and a higher complication rate, with the bar remaining for 2 or more years. This technique is less applicable to older patients and those with asymmetric deformities. Long-term follow-up will be necessary to determine which operation may be best for any specific patient.

Management of ovarian cysts in women undergoing restorative proctocolectomy for ulcerative colitis.

More than half of all patients undergoing restorative proctocolectomy (RP) for ulcerative colitis (UC) are women, yet there is a paucity of information regarding the frequency, management, and outcome of ovarian cysts. A single surgeon's (E.W.F.) experience with female patients (N = 165) who underwent RP for UC at an academic medical center was retrospectively evaluated for postoperative complications and overall outcome. Patients with large ovarian cysts (LOCs), defined as being greater than 5 cm in diameter, were further segregated for subanalysis. All results were analyzed using the Student's t test and Fisher's exact test. Patients were 29.3 +/- 13 years (mean) at the time of RP; 34 patients were less than 16 years old (21%), 113 patients (68%) were between the ages of 17 and 46 years, and 18 patients were over 46 years old (11%). All patients underwent total colectomy, mucosal proctectomy ileal pouch-anal anastomosis, and temporary end ileostomy. The ileostomy was closed 3 months later. Fifty-five of the 165 patients had ovarian cysts (33%) identified at operation, 46 had unilateral cysts, and nine had bilateral cysts. Mean ovarian cyst size was 4.6 +/- 2.7 cm (range <1-13 cm); 14 were LOCs. Patients with cysts <3 cm in diameter at operation were treated by observation with hormonal manipulation. Seventeen patients with cysts 3 to 5 cm in diameter required partial resection of one or both ovaries. Six of 14 patients with LOC underwent unilateral oophorectomy (cyst size range 10-13 cm). Twelve patients presented within 3 years after RP with malfunction of the pouch because of adhesions or minimal and uncontrolled passage of fecal material (soiling), partial obstruction due to LOC compression of the ileoanal pouch (n = 6), or adhesions. When evaluated on the basis of ovarian cyst size those without cysts and those with small cysts were significantly more likely to have children than those with LOC: 54 of 110 patients without cysts (49%), 18 of the 41 with cysts less than 5 cm in diameter (44%), and two of the 14 patients with LOC (14%) have had children (P = 0.047). Ovarian cysts are common in women undergoing RP for UC. Ovarian cysts often complicate postoperative intestinal function and are best treated by cyst resection or oophorectomy at the time of RP or ileostomy closure. Cysts under 3 cm in diameter may often be managed conservatively with few complications. Women with LOC after RP for UC have decreased fertility compared with those without cysts.

Morbidity and mortality of short-bowel syndrome in infants with abdominal wall defects.

Total parenteral nutrition (TPN) has made survival beyond infancy possible for many infants who have sustained small intestinal loss as a result of gastroschisis or omphalocele. The length and quality of life in these patients have often been limited by the development of late sequelae secondary both to the protracted use of TPN and the long-term complications of a shortened gut. This study was undertaken to determine what factors influence the morbidity and mortality of short-bowel syndrome (SBS) due to gastroschisis or omphalocele. A retrospective chart review of 850 infants who received TPN from January 1977 through December 1999 was carried out. All infants were treated at one academic medical center; those who had received > or =3 months of TPN were further segregated and their diagnosis, surgical procedures, length of bowel, ability to wean from TPN, follow-up weight and height, and developmental progress were recorded. Seventeen children were identified with SBS and either gastroschisis or omphalocele. Tight primary or secondary closure of the abdominal wall was believed to be a major cause of bowel necrosis and SBS in at least ten of the 17 patients. Overall survival was 76 per cent (13/17); survival was correlated with length of remaining bowel and was 86 per cent in patients having more than 15 cm of small bowel remaining but only 33 per cent in patients with less than 15 cm of small bowel remaining (P = 0.05). A longer length of residual small bowel resulted in a significantly shorter duration of TPN with a mean duration of 1.0 year for survivors having >38 cm and 10.0 years for survivors with <38 cm of bowel remaining (P = 0.03). Hepatic dysfunction with progressive failure resulting from TPN was related to death in three of the four nonsurvivors. The presence or absence of an ileocecal valve appeared unrelated both to the success of TPN weaning and to the length of time on TPN (P > 0.2). Eight of the 13 survivors have no ileocecal valve; five have undergone >50 per cent colonic resection. Nine of the survivors have adapted to enteral feedings (mean 36 +/- 60 months) during which time weaning from TPN occurred. The mean age of survivors is 7.9 +/- 5.1 years. Near-normal weights (defined as exceeding the fifth percentile for weight) were achieved for 92 per cent of the patients (12/13) with 46 per cent of the patients (6/13) exceeding the 50th percentile. Near-normal heights (exceeding the fifth percentile) were achieved for 77 per cent of the patients (10/13) with 15 per cent of the patients (2/13) exceeding the 50th percentile. Quality of life was measured on the basis of return to public school: nine of ten school-age survivors attend school and eight are normal without signs of developmental delay. Tight abdominal closure of gastroschisis or omphalocele may cause bowel necrosis and SBS. TPN has improved the long-term survival and quality of life in infants with SBS.

Increasing social capital via local networks: analysis in the context of a surgical practice.

The relationship between social capital (support, trust, patient awareness, and increased practice revenue) and local networks (university hospital) in communities has received little attention. The development of computer-based communication networks (social networks) has added a new dimension to the argument, posing the question of whether local networks can (re-)create social capital in local communities. This relationship is examined through a review of the literature on local networks and social capital and a surgeon's practice management from 1990 to 2001 with respect to repair of pectus chest deformities. With respect to pectus repair there was a consistent but small number of new referrals (15-20 new patients/year), lack of patient awareness (eight to 12 self-referred patients/year), and modest practice revenue. Since the inception of an Internet website (social network) dedicated to pectus repair in 1996 there has been increased social participation (n = 630 hits/year to the website); facilitation of spread of information through E-mail messages (n = 430 messages/year); and a greater participation of groups such as women, minorities, adults, and those with disability (n = 120 patients/year). The dissemination of information via the local network has also allowed an "outward movement" with increased participation by interconnecting communities (n = 698,300 global Internet participants based on statistical ratios). We conclude that local networks have enhanced social networks providing new grounds for the development of relationships based on choice and shared interest.