Differential Reactions of Soybean Isolines With Combinations of Aphid Resistance Genes Rag1 , Rag2 , and Rag3 to Four Soybean Aphid Biotypes.

With the discovery of the soybean aphid ( Aphis glycines Matsumura) as a devastating insect pest of soybean ( Glycine max (L.) Merr.) in the United States, host resistance was recognized as an important management option. However, the identification of soybean aphid isolates exhibiting strong virulence against aphid resistance genes ( Rag genes) has highlighted the need for pyramiding genes to help ensure the durability of host resistance as a control strategy. In this study, soybean isolines with all possible combinations of the resistance and susceptibility alleles at Rag1 , Rag2 , and Rag3 were evaluated for their effectiveness against the four characterized soybean aphid biotypes. All soybean isolines, including the susceptible check carrying none of the resistance alleles (S1/S2/S3), were infested with each biotype in no-choice greenhouse tests, and the aphid populations developed on each isoline were enumerated 14 d after infestation. All gene combinations, with the exception of Rag3 alone, provided excellent protection against biotype 1. Isolines with Rag2 alone or in combination with Rag1 and Rag3 had greater levels of resistance to biotype 2 than those with either Rag1 alone, Rag3 alone, or the Rag1/3 pyramid. For biotype 3, the Rag1/3 and Rag1/2/3 pyramided lines significantly reduced aphid populations compared with all other gene combinations, while the Rag1/2/3 pyramid provided the greatest protection against biotype 4. Overall, the Rag1/2/3 pyramided line conferred the greatest protection against all four biotypes.

Comparison of Pathogenic Variation among Phakopsora pachyrhizi Isolates Collected from the United States and International Locations, and Identification of Soybean Genotypes Resistant to the U.S. Isolates.

A major constraint in breeding for resistance to soybean rust has been the virulence diversity in Phakopsora pachyrhizi populations. In greenhouse experiments, reactions of 18 soybean genotypes to 24 U.S. isolates from 2007 and 2008 and 4 foreign isolates were compared. Reactions of four differentials (Rpp1 to Rpp4) to these U.S. isolates were also compared with reactions to nine foreign isolates and three U.S. isolates from 2004. Principal component analysis (PCA) of the reaction types grouped the U.S. isolates into a single virulence group, whereas each of the foreign isolates had a unique virulence pattern. In another experiment, reactions of 11 differentials to the 24 U.S. isolates were compared and significant interactions (P < 0.001) were found between the isolates and host genotypes for rust severity and uredinia densities. PCA of these two measures of disease placed the 24 isolates into seven or six aggressiveness groups, respectively. In a third experiment, evaluation of 20 soybean genotypes for resistance to the previously established aggressive groups identified 10 genotypes resistant to isolates representing most of the groups. This study confirmed the pathogenic diversity in P. pachyrhizi populations and identified soybean germplasm with resistance to representative U.S. isolates that can be used in breeding.

Characterization and quantification of fungal colonization of Phakopsora pachyrhizi in soybean genotypes.

Soybean rust, caused by the fungus Phakopsora pachyrhizi, is an economically important disease of soybean with potential to cause severe epidemics resulting in significant yield losses. Host resistance is one of the management tools to control this disease. This study compared soybean genotypes exhibiting immunity, complete and incomplete resistance, and susceptibility to an isolate of P. pachyrhizi based on visual assessment of reaction type, other visual traits such as sporulation, quantitative measurements of the amount of fungal DNA (FDNA) present in leaf tissues, and data on infection and colonization levels. Soybean genotype UG5 (immune), and plant introduction (PI) 567102B and PI 567104B (complete resistance) had lower quantities of uredinia and FDNA than four other genotypes with incomplete resistance. Based on microscopic observations, early events of spore germination, appressorium formation, and fungal penetration of the epidermis occurred within 24 h postinoculation and were similar among the tested soybean genotypes. Differences in infection among the genotypes were evident once the hyphae penetrated into the intercellular spaces between the mesophyll cells. At 2 days after inoculation (dai), soybean genotype Williams 82 had a significantly (P < 0.05) higher percentage of hyphae in the mesophyll tissue than other soybean genotypes, with UG5 having significantly (P < 0.05) lower percentages than all of the other soybean genotypes at 3, 4, and 5 dai. The percentage of interaction sites with mesophyll cell death was significantly (P < 0.05) higher in UG5 than other genotypes at 3, 4, and 5 dai. There was a significant positive correlation (r = 0.30, P < 0.001) between quantities of hyphae in the mesophyll cells and FDNA. These results demonstrated that incompatible soybean-P. pachyrhizi interaction results in restricted hyphal development in mesophyll cell tissue, likely due to hypersensitive apoptosis.

Effect of Fungicide Application and Cultivar on Soybean Green Stem Disorder.

Green stem disorder of soybean (Glycine max) has increasingly become a nuisance for soybean producers. The disorder is distinguished from other manifestations of delayed plant maturity by the delayed senescence of stems only, with normal pod ripening and seed maturation. The primary objective of the first study was to determine whether green stem disorder increased with a fungicide treatment. Field cages to isolate soybean plants to prevent insect interactions were used and treatments included maturity group (MG) II insensitive and sensitive soybean cultivars with or without fungicide applications. A secondary objective was to determine fungi potentially associated with the disorder. The results indicated significant elevation of the incidence of green stem disorder when using a fungicide. Species of Diaporthe or Phomopsis and Macrophomina phaseolina were more frequent in stems without the disorder, whereas species of Colletotrichum were found mostly in stems with the disorder. In another study, field experiments were conducted without cages in replicated field plots to compare the effects of fungicides with different chemistries and timing of fungicide application on incidence of green stem disorder using green stem disorder MG II- and MG III-sensitive and insensitive soybean cultivars. There was a significant increase in percentage of green stem disorder due to fungicide application, depending on fungicide chemistry, timing of application, year, location, and cultivar sensitivity to green stem disorder. Generally, Headline and Headline-Domark applications resulted in higher incidence of green stem disorder than Domark alone or the nonsprayed control, with over 50% incidence in many cases. Higher percent green stem disorder was significantly (P < 0.05) associated with higher yields in 11 of the 28 trials. From the results of this research, soybean producers should be aware of the possible risk that fungicide application may have in increasing incidence of green stem disorder. In addition, producers can help manage green stem disorder by selecting soybean cultivars reported to be consistently insensitive to the disorder.

A Cut-Stem Inoculation Technique to Evaluate Soybean for Resistance to Macrophomina phaseolina.

Charcoal rot of soybean is caused by the fungal pathogen Macrophomina phaseolina. Effective and reliable techniques to evaluate soybean for resistance to this fungus are needed to work toward a management scheme that would utilize host resistance. Three experiments were conducted to investigate the use of a cut-stem inoculation technique to evaluate soybean genotypes for resistance to M. phaseolina. The first experiment compared aggressiveness of M. phaseolina isolates collected from soybean on different soybean genotypes. Significant (P < 0.05) differences among the isolates and genotypes for relative area under disease progress curve (RAUDPC) were found without a significant isolate-genotype interaction. The second experiment compared 14 soybean genotypes inoculated with M. phaseolina in multiple trials conducted in two environments, the greenhouse and growth chamber. Significant (P < 0.05) differences among environments and highly significant (P < 0.001) differences among soybean genotypes for RAUDPC were found. The environment-genotype interaction was nonsignificant (P > 0.05). Soybean genotypes DT97-4290, DT98-7553, DT98-17554, and DT99-16864 had significantly (P < 0.05) lower RAUDPC than 7 of the 14 genotypes. The third experiment evaluated resistance in selected Phaseolus spp. and soybean genotypes. The range of RAUDPC for Phaseolus spp. was similar to that of soybean. The Phaseolus lunatus 'Bush Baby Lima' had significantly (P < 0.05) lower RAUDPC than P. vulgaris genotypes evaluated. The cut-stem inoculation technique, which has several advantages over field tests, successfully distinguished differences in aggressiveness among M. phaseolina isolates and relative differences among soybean genotypes for resistance to M. phaseolina comparable with results of field tests.

Comparisons of Visual Rust Assessments and DNA Levels of Phakopsora pachyrhizi in Soybean Genotypes Varying in Rust Resistance.

Soybean resistance to Phakopsora pachyrhizi, the cause of soybean rust, has been characterized by the following three infection types: (i) immune response (IM; complete resistance) with no visible lesions, (ii) resistant reaction with reddish brown (RB) lesions (incomplete resistance), and (iii) susceptible reaction with tan-colored (TAN) lesions. Based on visual assessments of these phenotypes, single gene resistance in soybean to P. pachyrhizi has been documented, but colonization within infected tissues based on fungal DNA (FDNA) levels in different soybean genotypes had not been analyzed. The research used a quantitative polymerase chain reaction (Q-PCR) assay to compare visual disease assessment to FDNA in controlled inoculation experiments using two isolates of P. pachyrhizi. The objective of the first experiment was to compare data from digital visual disease assessment to FDNA from Q-PCR assays using digital visual disease assessment using five resistant soybean genotypes (one IM and four RB) and five susceptible genotypes (TAN). The objective of the second experiment was to quantify FDNA using Q-PCR at different time points after inoculation to determine if levels of fungal colonization differed in five soybean genotypes with different levels of resistance (one IM, two RB, and two TAN). For experiment 1, the numbers of uredinia and uredinia per lesion on four of the five resistant soybean genotypes were lower (P < 0.05) than the other six genotypes. Significant differences (P < 0.05) in FDNA concentrations were found among soybean genotypes with TAN lesions and among soybean genotypes with RB lesions. Soybean cultivar UG5 (IM phenotype) had significantly less (P < 0.05) FDNA than all of the other genotypes. Some genotypes that produced TAN lesions had significantly lower (P < 0.05) or non-significantly different FDNA concentrations compared to those genotypes that produced RB lesions. For experiment 2, the regression of FDNA on days after inoculation was significant (P < 0.01) with positive slopes for all genotypes except for UG5, in which FDNA declined over time, indicating a reduction of fungal colonization. The results of this Q-PCR FDNA screening technique demonstrates its use to distinguish different types of resistance, and could be used to facilitate the evaluation of soybean breeding populations, where precise quantification of incomplete and/or partial resistance is needed to identify and map quantitative trait loci.

Carbon utilization profiles of Fusarium virguliforme isolates.

Fusarium virguliforme is the cause of sudden death syndrome in soybean. Physiological variability among isolates of the fungus is unknown. One way to measure physiologic variability is to analyze growth on different carbon sources. The carbon source utilization profiles of 18 F. virguliforme isolates were examined using the Biolog FF 96-well microplate, which contains 95 different carbon sources. The utilization of dextrin,D-mannitol, maltotriose,D-lactic acid methyl ester, N-acetyl-D-galactosamine, salicin, D-trehalose, and L-alanine differed significantly among isolates (P = 0.05). Carbon sources were grouped into 3 clusters based on their ability to promote growth of F. virguliforme, after calculating Euclidean distances among them. About 12% of the carbon sources promoted a high amount of mycelial growth, 39% promoted a medium amount of growth, and 49% promoted a low amount of mycelial growth; the latter was not significantly different from the water blank control. A hierarchical tree diagram was produced for the 18 isolates based on their carbon source utilization profiles using Ward's hierarchical analysis method. Two main clusters of isolates were formed. One cluster represented greater average mycelial growth on all of the carbon sources than the other cluster. In this study, variability in carbon source utilization among F. virguliforme isolates was evident, but the results were not associated with geographic origin of the isolates, year collected, or published data on aggressiveness. Additional research is needed to determine if these carbon utilization profiles are associated with other biological characteristics, like spore germination, propagule formation, and saprophytic competitiveness.

Production of Macrophomina phaseolina Conidia by Multiple Soybean Isolates in Culture.

Macrophomina phaseolina is the cause of charcoal rot of soybean (Glycine max). Resistance to M. phaseolina in commercial soybean cultivars is not common but is needed in locations where the disease is chronic and severe. The objective of this study was to develop a reliable method to produce sufficient M. phaseolina conidia that can be used to inoculate soybean plants in a high-throughput resistance-screening program. Production of pycnidia is not common on most culture media, such as potato dextrose agar, but can be produced on media containing plant parts or oilseed extracts. Seven semi-defined media were tested to induce pycnidia production. Results indicated that the number of pycnidia that were produced by eight M. phaseolina isolates was dependent on induction medium; however, peanut butter extract-saturated filter paper placed over soynut butter extract agar (PESEA) allowed for greater pycnidia and conidia production than the other media tested. Production of pycnidia on PESEA ranged from 269 to 1,082 per plate. There were no differences among isolates in germination of conidia produced on PESEA, which averaged 83 ± 2% germination. A conidial suspension from one M. phaseolina isolate produced on PESEA and inoculated onto soybean radicles significantly distinguished (P < 0.01) 'DT97-4290', a soybean genotype with partial resistance to charcoal rot, from a susceptible genotype, 'LS98-0358'. Results of this study indicated that multiple isolates of M. phaseolina from soybean produced sufficient amounts of conidia on PESEA to use as inoculum. This conidia inoculum production method will facilitate soybean charcoal rot resistance screening evaluation with different soybean isolates.

Differential Responses of Resistant Soybean Entries to Isolates of Phakopsora pachyrhizi.

Soybean rust, caused by the fungus Phakopsora pachyrhizi, was detected in the continental United States in 2004. Several new sources of resistance to P. pachyrhizi have been identified in soybean (Glycine max); however, there is limited information about their resistance when challenged with additional U.S. and international isolates. Resistance of 20 soybean (G. max) entries was compared after inoculation with 10 P. pachyrhizi isolates, representing different geographic and temporal origins. Soybean entries included 2 universal susceptible cultivars, 4 sources of soybean rust resistance genes (Rpp1-4), and 4 and 10 resistant entries selected from field trials in Paraguay and Vietnam, respectively. Of the known Rpp1-4 sources of resistance, plant introduction (PI) 459025B (Rpp4) produced reddish-brown (RB) lesions in response to all of the P. pachyrhizi isolates, while PI 230970 (Rpp2) produced RB lesions to all isolates except one from Taiwan, in response to which it produced a susceptible tan (TAN) lesion. PI 200492 (Rpp1) and PI 462312 (Rpp3) produced TAN lesions in response to most P. pachyrhizi isolates. The resistant entries selected from Paraguay and Vietnam varied considerably in their responses to the 10 P. pachyrhizi isolates, with M 103 the most susceptible and GC 84058-18-4 the most resistant. The reaction patterns on these resistant entries to the P. pachyrhizi isolates were different compared with the four soybean accessions with the Rpp genes, indicating that they contain novel sources of rust resistance. Among the P. pachyrhizi isolates, TW 72-1 from Taiwan and IN 73-1 from India produced the most susceptible and resistant reactions, respectively, on the soybean entries.

Green Stem Disorder of Soybean.

Green stem disorder of soybean (Glycine max) is characterized by delayed senescence of stems with normal pod ripening and seed maturation. Three different field research approaches were designed to determine the relationship of green stem disorder to Bean pod mottle virus (BPMV) and other potential factors that may be involved in causing this disorder. The first research approach surveyed green stem disorder and BPMV in individual plants monitored in several commercial soybean fields during three growing seasons. Leaf samples from maturing plants (growth stage R6) were tested by enzyme-linked immunosorbent assay (ELISA) for BPMV. The percentage of monitored plants infected with BPMV at growth stage R6 in some fields was higher than the incidence of green stem disorder at harvest maturity. Many plants infected with BPMV did not develop green stem disorder, and conversely, many plants that had green stem disorder were not infected with BPMV. According to a chi-square test of independence, the data indicated that green stem disorder was independent of BPMV infection at growth stage R6 (P = 0.98). A second research approach compared green stem disorder incidence in an identical set of soybean entries planted in two locations with different levels of natural virus infection. Despite differences in virus infection, including BPMV incidence, 20 of 24 entries had similar green stem disorder incidence at the two locations. A third research approach completed over two growing seasons in field cages showed that green stem disorder developed without BPMV infection. BPMV infection did not increase green stem disorder incidence in comparison to controls. Bean leaf beetle, leaf hopper, or stinkbug feeding did not have an effect on the incidence of green stem disorder. The cause of the green stem disorder remains unknown.

Occurrence of Seed Coat Mottling in Soybean Plants Inoculated with Bean pod mottle virus and Soybean mosaic virus.

Soybean seed coat mottling often has been a problematic symptom for soybean growers and the soybean industry. The percentages of seed in eight soybean lines with seed coat mottling were evaluated at harvest after inoculating plants during the growing season with Bean pod mottle virus (BPMV), Soybean mosaic virus (SMV), and both viruses inside an insect-proof cage in the field. Results from experiments conducted over 2 years indicated that plants infected with BPMV and SMV, alone or in combination, produced seed coat mottling, whereas noninoculated plants produced little or no mottled seed. BPMV and SMV inoculated on the same plants did not always result in higher percentages of mottled seed compared with BPMV or SMV alone. There was significant virus, line, and virus-line interaction for seed coat mottling. The non-seed-coat-mottling gene (Im) in Williams isoline L77-5632 provided limited, if any, protection against mottling caused by SMV and none against BPMV. The Peanut mottle virus resistance gene Rpv1 in Williams isoline L85-2308 did not give any protection against mottling caused by SMV, whereas the SMV resistance gene Rsv1 in Williams isoline L78-379 and the resistance gene or genes in the small-seeded line L97-946 gave high levels of protection against mottling caused by SMV. The correlations (r = 0.77 for year 2000 and r = 0.89 for year 2001) between virus infection of the parent plant and seed coat mottling were significant (P = 0.01), indicating that virus infection of plants caused seed coat mottling.

Wireless replacement of the "lost" central venous line in children.

Although the achievement of central venous access in children is often difficult maintenance of access is often frustrated by the tendency of the small-caliber central venous line (CVL) to thrombose despite adequate heparinization or-worse yet-be inadvertently removed. Traditional replacement over wire (Seldinger technique) is often not an option for these "lost" CVLs. Over the past 7 years we have used a wireless technique of CVL replacement to re-establish central access in children. The charts of 125 children who underwent wireless CVL replacement at various institutions between January 1995 and July 2000 were retrospectively reviewed. The wireless technique involves replacement of CVL by direct insertion through the previous catheter tract marked by the old puncture site. Plain film was used to confirm the line position postprocedure. The technique was applied predominantly to percutaneously placed 3- to 4-F CVLs with distal port thrombosis or those that had been inadvertently removed. Successful replacement was defined as re-establishment of previous line position and the ability to flush/draw blood through all ports. Wireless replacement was successful in 120 of 125 cases (96.0%). Recannulization was successful in CVLs as new as 3 days old and those removed for as long as 24 hours. Of the five unsuccessful cases, however, two CVLs were >3 weeks old, but >6 hours had elapsed since removal. The remaining three cases were CVLs that were <3 days old. There were no intra- or postoperative complications, notably air embolism. We conclude that wireless CVL replacement in children can be performed safely and successfully in children who have lost central access not amenable to replacement via the traditional Seldinger technique. The often difficult chore of re-establishing central access at a new site in small children can thus be avoided.

Video-assisted thoracoscopic surgery for children with stage II empyema.

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.

Transanal mucosectomy in the treatment of Hirschsprung's disease.

BACKGROUND/PURPOSE: Transanal mucosectomy of the aganglionic segment of colon is a critical step in minimally invasive surgery for Hirschsprung's disease. The purpose of this study was to examine the outcome of patients undergoing transanal mucosectomy. METHODS: From January 1979 to November 1998, 26 patients (ages 25 days to 17 years) underwent transanal mucosectomy for Hirschsprung's disease. Seventeen (65%) had partial transanal mucosectomy (PTM; 1979 to 1998) and 9 (35%) complete transanal mucosectomy (CTM; 1995 to 1998). In PTM, a 2- to 3-cm mucosal dissection was begun 1 cm above the dentate line in conjunction with transabdominal endorectal dissection (modified Soave). In CTM, the entire mucosal dissection was performed transanally as part of a laparoscopically assisted Soave procedure. Results were obtained by chart review and personal communication. Patients were assessed clinically for continence where age appropriate (>3 years) and for development of constipation, postoperative enterocolitis, and anal stricture. RESULTS: One of 16 (6.2%) of the PTM group was incontinent versus none (4 patients) in the CTM group. Five of 17 (29.4%) of the PTM group were constipated versus 4 of 9 (44.4%) in the CTM group (t test, P = not significant). Postoperative enterocolitis developed in 4 of 17 (23.5%) of the PTM group versus 6 of 9 (66.6%) in the CTM group (t test, P<.05). Three of 6 (50%) of the CTM group versus none in the PTM group required hospitalization for bowel rest, rectal washouts, and antibiotics. All patients were well at the time of the report. Anal stricture was not seen in either group. CONCLUSIONS: Constipation and postoperative enterocolitis are a significant feature of transanal mucosectomy for Hirschsprung's disease deserving close surveillance, especially in patients in whom the entire mucosal dissection was performed transanally. Continence appears to be satisfactorily preserved from these preliminary results.

Laparoscopic fundoplication in children with previous abdominal surgery.

BACKGROUND/PURPOSE: In our institution, many children requiring antireflux surgery for gastroesophageal reflux have had previous abdominal surgery, usually gastrostomy tube or ventriculoperitoneal (VP) shunt placement. The authors review their laparoscopic Nissen fundoplication (LNF) experience in children with previous abdominal surgery assessing surgical outcome. METHODS: A total of 82 consecutive LNFs performed at our institution between January 1996 and September 1998 were reviewed. Follow-up ranged from 1 month to 32 months (average, 8.9 months). LNF was performed without dividing short gastric vessels (Rosetti modification) through a standard 5-port technique. RESULTS: A total of 26 of 82 patients (31.7%) had previous abdominal surgery and were divided into 2 groups: gastrostomy (n = 17) and VP shunt (n = 11) with 2 crossovers. A total of 14 of 17 (82.3%) in the gastrostomy group had percutaneous endoscopic gastrostomy (PEG) placement versus 3 of 17 (17.6%) by open technique (open). Four patients in the VP group had multiple surgeries (range, 1 to 10, average, 2.3). LNF was completed in 25 of 26 (96.2%). One operation was converted to an open procedure because of severe adhesions. In 13 of 17 (76.5%) the previous gastrostomy was not taken down. In 4 of 17 (23.5%), the gastrostomy was taken down to complete the procedure: 2 of 3 (66.7%) of the open group versus 2 of 14 (14.3%) of the PEG group. All 11 (100%) of the VP group had successful LNF. Two of 11 (18.2%) had shunt dysfunction at 2 months (shunt infection) and 4 months (clogged distal shunt), respectively. There have been no cases of recurrent reflux, and all gastrostomies and VP shunts were functional at the time of this report. CONCLUSIONS: Previous abdominal surgery is common in children with gastroesophageal reflux disease requiring an antireflux procedure. The authors conclude from these preliminary results that laparoscopic Nissen fundoplication can be performed safely with minimal morbidity and excellent functional results in children with gastrostomies or ventriculoperitoneal shunts.

Laparoscopic splenectomy in children with hematological disorders: preliminary experience at the Children's Hospital of New Orleans.

Minimally invasive surgery has recently gained acceptance as the surgical approach of choice for a variety of surgical disorders in children. Although traditional open surgery is still regarded as the standard approach for a splenectomy in children when necessary for hematologic disorders a few cases of successful laparoscopic splenectomy (LS) have been reported. We present our initial 11 cases of LS in children assessing surgical outcome. Eleven patients ages 2 through 15 years underwent LS between June of 1996 and July of 1999 at the Children's Hospital of New Orleans. Indications for surgery included idiopathic thrombocytopenic purpura, congenital spherocytosis, and hemolytic anemia. In all patients the diameter of the spleen was less than 15 cm. Surgical outcome was assessed according to the following parameters: operative time, postoperative length of stay, postoperative morbidity, and cosmetic results. Data were accumulated on the basis of retrospective chart review. LS was completed in all 11 patients. Postoperative morbidity was minimal and the median postoperative stay was 2.4 days (range 1-5). Mean operative time was 3 hours and 10 minutes (range 1.5-7 hours) with the last six procedures completed in an average of just over 2 hours. Intravenous analgesia was discontinued in <48 hours in all patients. Cosmetic results were judged excellent in all cases. We conclude that LS was safe in children with certain hematologic disorders. Adequate selection of patients, appropriate preoperative preparation of patients, meticulous surgical technique, and careful postoperative care were key factors in obtaining the same long-term results as with open surgery.

Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopic gastrostomy in children.

BACKGROUND: Abnormal gastroesophageal reflux after percutaneous endoscopic gastrostomy is a serious problem in neurologically impaired children. Protective fundoplication has been advocated. Whether esophageal pH monitoring before percutaneous endoscopic gastrostomy will predict later problems with gastroesophageal reflux is unclear. METHODS: Eighty-five mostly neurologically impaired pediatric patients who underwent percutaneous endoscopic gastrostomy were studied retrospectively regarding complications, success of nutritional rehabilitation, and the incidence of pathologic gastroesophageal reflux. Follow-up period was 1 to 4 years. Twenty-four-hour esophageal pH monitoring was performed in 46 patients before percutaneous endoscopic gastrostomy. RESULTS: There were no deaths. Two major complications occurred that required surgical intervention, and 14 minor complications occurred related to the procedure. Z-scores for weight increased significantly after percutaneous endoscopic gastrostomy. pH probe results were normal in 22 patients (group 1). Five required medical treatment for gastroesophageal reflux after percutaneous endoscopic gastrostomy, but only 1 (5%) later required Nissen fundoplication. pH probe results were abnormal in 24 patients (group 2). Nineteen required medical therapy for gastroesophageal reflux, and 7 (29%) later needed fundoplication (p < 0.05, incidence of fundoplication group 1 vs. group 2). Improvement in Z-scores was similar in patients requiring and not requiring fundoplication. CONCLUSIONS: Percutaneous endoscopic gastrostomy is a safe and effective technique for long-term nutritional support in children. Abnormal gastroesophageal reflux is common. Normal findings in an esophageal pH study before percutaneous endoscopic gastrostomy may be predictive of a favorable outcome with respect to gastroesophageal reflux. This is in contrast to patients with abnormal results in pH studies before percutaneous endoscopic gastrostomy of whom a relatively large percentage may later require fundoplication. Improved nutritional status after percutaneous endoscopic gastrostomy does not appear to have an impact on the severity of gastroesophageal reflux.

Cure of hypoglycemic hyperinsulinism by enucleation of a focal islet cell adenomatous hyperplasia.

During pancreatectomy for refractory neonatal hyperinsulinemic hypoglycemia, a well-delineated focal adenomatous hyperplasia was enucleated. Intraoperative glucose levels returned to normal and pancreatectomy was averted. Seven months later the child is euglycemic. This experience suggests that during surgery for neonatal refractory hypoglycemia, a focal lesion should be sought, and if found, enucleated, and blood glucose monitored. If the glucose rises to euglycemic levels or above, the child should be monitored clinically. If sustained elevation is not maintained, a search for an additional focal lesion or pancreatectomy should be performed. Saving the pancreas may prevent future development of diabetes mellitus.