Neil J. Sherman

Hamartomas of the chest wall in infants

Chest wall hamartomas in infancy are rare lesions with distinct clinical, radiologic, and pathologic characteristics. Four cases treated at Childrens Hospital of Los Angeles are presented and previously reported cases are reviewed. Chest wall hamartomas arise antenatally and present as hard, immobile masses, which may cause respiratory insufficiency. An extrapleural mass arising from the ribs can be seen radiographically. Histologically, these lesions are hypercellular and consist of a disorganized array of mesenchymal tissues endogenous to the chest wall. Rapid growth may occur, but usually is self-limited. Chest wall hamartomas are usually benign. This series includes the malignant transformation of one of these lesions. En bloc resection is curative, but the large residual chest wall defect frequently results in scoliosis.

Regional enteritis in childhood

Abstract This report is a clinical review of 28 children with Crohns disease hospitalized at the Childrens Hospital of Los Angeles during the past 12 yr. In addition to the usual reasons for surgery, growth failure was a common indication. Surgical resection was performed on 18 patients with a follow-up ranging from 1 to 10 yr, and encouraging early results. The importance of close medical follow-up, with surgical intervention when necessary, is emphasized.

A triple duplication of the alimentary tract

Duplications of the alimentary tract occur infrequently, and are usually isolated anomalies. In the infant described below, a complex clinical picture was the result of three distinct duplication in widely separated portions of the alimentary tract (esophagus, duodenum, ileum). Details of the clinical course and technical management of an extremely long ileal duplication form the basis for this report.

Use of a subclavian venous catheter for short- and long-term hemodialysis in children

Vascular access for hemodialysis in children poses problems not encountered in adults because of the small size of the vessels available. The increasing use of peritoneal dialysis has created a large number of patients who need prompt access for hemodialysis for days to weeks during episodes of peritonitis. There are also occasional patients who have exhausted available fistula sites and still require hemodialysis. To address these problems, we designed a series of catheters for insertion in the subclavian vein. The catheters are stiffer than the Hickman type catheter to allow for higher flow rates without collapse. Seventy-five catheters were implanted in 58 patients with a mean age of 14 years. Twelve catheters were inserted in ten children for long-term (over 3 months) access; they have been in place for a mean of 259 days and used for a mean of 64 dialyses. In two children, the catheter has been the sole site for hemodialysis for over a year. Fifty-eight catheters were implanted in 43 patients for short-term hemodialysis. They were in place for a mean of 29 days and used for a mean of 13 dialyses. The major complications encountered were clotting of the catheter and migration out of position. Four catheters were removed because of infection. These new catheters provide effective hemodialysis for children as small as 7 kg with an acceptable morbidity rate and may be used for extended periods of time if necessary.

The Surgeon's role in chronic peritoneal dialysis

Hemodialysis has been the mainstay for children with end-stage renal disease until a successful renal transplant is accomplished. Chronic peritoneal dialysis has been a second choice and, in special circumstances such as for small infants, children without vascular access, or patients unstable on hemodialysis, it is the only alternative. Recent refinements in peritoneal catheters and dialysis have added to the many medical, psychological, and economic advantages, resulting in the displacement of hemodialysis by peritoneal dialysis as the most frequently used modality. Forty-six patients were followed for 593 catheter months on peritoneal dialysis. A total of 74 procedures were performed, and 56 catheters were implanted. Complications included infection and mechanical occlusion of the catheter. Peritonitis occurred in 13 of the 46 patients on 56 separate occasions. There were 5 episodes of subcutaneous catheter infection. The peritonitis was treated with medical therapy alone in 50 of the 56 episodes of peritonitis. Mechanical occlusion in 10 patients and remedial surgery was required in 9. Of the total series, 4 patients were returned to hemodialysis and 5 patients died. Based on this experience we have developed guidelines to assist the surgeon in preventing and treating the various complications associated with chronic peritoneal dialysis.