Thoracic surgical problems in infancy and childhood.

Thoracic surgical problems in infants and children range from congenital anomalies to acquired inflammatory problems. This article reviews the most common parenchymal, pleural, and mediastinal problems encountered in infants and children and presents recommendations for prompt and accurate diagnosis and therapy.

Extra-anatomical vascular bypass and external skeletal fixation in limb replantation.

The scientific background for limb replantation began 75 yr ago with the work of Hopfner and of Carrel and Guthrie. Thirty-five years ago, Hall indicated that the techniques were available, but it was not until 17 yr ago that Malt and McKhann performed the first successful replantation of a limb in man. Since then, the techniques have become more sophisticated and guidelines have been formulated. Many successful replantations have been reported. We present two children with partial amputation of a lower limb. Both had severe soft tissue and bone damage sufficient to contraindicate replantation by conventional criteria. Wound sepsis resulted in failure of replantation of the first child's limb replanted by conventional methods. The second child's limb was salvaged. Extra-anatomical vascular bypass graft separated the critical vascular anastomoses from the open contaminated wound. External skeletal fixation allowed aggressive open wound treatment. In selected cases, these two techniques would appear to increase the chances for successful limb replantation.

Pinhold imaging: utility in testicular imaging in children.

Pinhole imaging of the testis was done in ten boys with suspected testicular torsion. In three of the ten cases, pinhold images were easier to interpret than images obtained with a converging collimator. In six of the ten cases, pinhold images were required for interpretation of the study, because converging images could not be interpreted.

Pulmonary vascular sling with tracheobronchial stenosis and hypoplasia of the right pulmonary artery.

We present a case of pulmonary sling associated with tracheobronchial stenosis, and with hypoplasia of the right lung and right pulmonary artery. Radiologic studies showed evidence of pulmonary sling and hypoplasia of the right lung; associated hypoplasia of the right pulmonary artery was also present, but not recognized initially. Narrowing of the distal trachea and right main bronchus was present, not due to compression by the anomalous left pulmonary artery, but to congenital stenosis of the trachea and right main bronchus associated with complete cartilaginous tracheobronchial rings.

Retroperitoneal lymph node dissection for Wilms' tumor.

Nephrectomy for Wilms' tumor was performed on 58 patients over a 20-yr period, and retroperitoneal lymphadenectomy was performed on 35 who presented with no demonstrable metastases. The survival rate was 100% for 19 clinical group I patients with negative nodes. Positive nodes in 9 instances led to 5 long-term survivors and significantly influenced staging as a guide for further therapy.

Renal homotransplantation in children.

Ninety-six renal transplants in 77 pediatric patients are reported with follow-up as long as 12 1/2 years. Thirteen of the first 14 patients are living with a functioning kidney after eight to 12 1/2 years. The patient survival for the entire group is 78%. Sixty-four percent are living with a functioning transplanted kidney. Splenectomy was initially performed at the time of transplant but has been discontinued because of concern that splenectomy in the immunosuppressed patient was related to an increased occurrence of septic complications. Anencephalic newborn infants have been found to be a satisfactory source of cadaver donor kidneys. Growth and development have been satisfactory when the transplant is performed prior to 12 years of age, if it functions well, and if an alternate-day regimen of steroid administration is followed. Both boys and girls have now passed through puberty with their transplanted kidneys, have married, become parents, and are leading essentially normal lives. A plea is made for earlier transplantation in small children with irreversible progressive renal failure before they develop severe stunting of growth and before the need for prolonged dialysis.

Leukemic infiltration of the testis during long-term remission.

Of 33 boys with acute lymphocytic leukemia treated at the Cincinnati Children's Hospital during 1971--1974, 14 remained in clinical and bone marrow remission for periods longer than 2.5 yr. Of these 14 patients, 8 then developed testicular leukemia. In 7 of these 8 patients, testicular infiltration was the first or only evidence of relapse. In 2 of the patients the gonads were not grossly abnormal, and testicular relapse was discovered as a result of routine wedge biopsy before therapy was to have been stopped. This experience has led to our policy of routine testicular biopsy in boys with acute lymphocytic leukemia who have had continuous remission for 3 yr and who are otherwise candidates for discontinuance of maintenance therapy.

Surgical closure of patent ductus arteriosus in the premature infant with respiratory distress.

During the period from February, 1971 to February, 1973, 30 premature infants underwent surgical ligation of patent ductus arteriosus. The gestational ages ranged from 25 to 36 wk (mean 30), and the birth weights ranged from 760 to 2010 g (mean 1274). The patients were divided into two groups on the basis of the indications for assisted ventilation. Group I consisted of 21 patients with severe hylanine membrane disease who required assisted ventilation during the first 2 days of life and could not be weaned off the respiratory by 10 days of age. Group II was composed of nine infants who required intermittent positive-pressure breathing after a mean age of 8 days because of repeated apneic spells secondary to uncontrollable heart failure. All infants in Group II survived the operation and left the hospital well. Fourteen of the 21 patients in Group I survived; the seven deaths were all due to underlying severe pulmonary disease (bronchopulmonary dysplasia). The value of PDA ligation in premature infants with uncontrollable heart failure is demonstrated in this study; this procedure also appears to be beneficial in neonates with severe respiratory distress syndrome.