A novel protocol for rapid deployment of heart rate data storage tags in Atlantic bluefin tuna Thunnus thynnus reveals cardiac responses to temperature and feeding.

The Atlantic bluefin tuna (ABFT) is a highly prized species of large pelagic fish. Studies of their environmental physiology may improve understanding and management of their populations, but this is difficult for mature adults because of their large size. Biologging of heart rate holds promise in investigating physiological responses to environmental conditions in free-swimming fishes but it is very challenging to anesthetize large ABFT for invasive surgery to place a tag in the body cavity near to the heart. We describe a novel method for rapid deployment of a commercially available heart-rate tag on ABFT, using an atraumatic trocar to implant it in the musculature associated with the cleithrum. We performed three sequential experiments to show that the tagging method (1) is consistently repeatable and reliable, (2) can be used successfully on commercial fishing boats and does not seem to affect fish survival, and (3) is effective for long-term deployments. In experiment 3, a tag logged heart rate over 80 days on a 60-kg ABFT held in a farm cage. The logged data showed that heart rate was sensitive to prevailing seasonal temperature and feeding events. At low temperatures, there were clear responses to feeding but these all disappeared above a threshold temperature of 25.5°C. Overall, the results show that our method is simple, rapid, and repeatable, and can be used for long-term experiments to investigate physiological responses by large ABFT to environmental conditions.

[Does prenatal diagnosis modify neonatal management and early outcome of children with esophageal atresia type III?]. / Le diagnostic anténatal modifie-t-il la prise en charge néonatale et le devenir à 1 an des enfants suivis pour atrésie de l'œsophage de type III ?

OBJECTIVE: Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III. STUDY DESIGN: Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year. RESULTS: Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P<0.001). Delay between birth and first intervention was not significantly different. Defect size (2cm vs 1.4cm, P<0.001), gastrostomy (21.6% versus 8.7%, P<0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P<0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P=0.044). CONCLUSION: Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.

[Acute intussusception, a rare cause of small bowel obstruction in premature neonates: the advantages of early diagnosis]. / L'invagination intestinale aiguë, cause rare de syndrome occlusif chez un nouveau-né prématuré : intérêt du diagnostic précoce.

We report a case of intussusception in a premature neonate who presented with early signs of upper gastrointestinal tract obstruction. Diagnosing acute intussusception in premature infants is difficult because of its infrequency relative to other neonatal abdominal problems and because the clinical symptomatology shows similarities with that of necrotizing enterocolitis. In the reported case, the diagnosis was made by sonography. Unlike full-term neonates, the presence of a pathological lead point is very infrequent. The intussusception is predominantly located in the small bowel and is most often associated with bowel compromise. This disease should be considered in all neonates with signs of intestinal obstruction to permit a better prognosis via prompt surgical intervention.

Lobectomía por toracoscopia en pediatría. Nuestra experiencia y nuevas perspectivas de tratamiento / Thoracoscopic lobectomy in pediatrics. our experience and new treatment perspectives

Objetivos. Las malformaciones pulmonares en el niño son un espectro anatómico-clínico diferenciado. Tanto la malformación adenomatoide quística (MAC) como el secuestro pulmonar producen una amplia gama de síntomas, desde las formas asintomáticas hasta las más graves, y su manejo permanece controvertido. Asimismo, en los últimos años han aparecido trabajos que muestran la realización adecuada de esta cirugía mediante toracoscopia, siendo una alternativa a la cirugía tradicional. En este trabajo analizamos nuestra experiencia en la realización de lobectomías por toracoscopia, que demuestra ser una técnica segura y con menos complicaciones que por toracotomía. Métodos. Durante los años 2004-2008 se realizaron lobectomías en seis pacientes, con edades comprendidas entre 1 semana y 15 años. Los diagnósticos eran MAC en 4 casos, asociado a secuestro pulmonar (..) (AU)

Objectives. Pulmonary malformations in the child are a wide clinical and pathologycal spectrum. The congenital cystic adenomatoid malformation and the pulmonary sequestration both produce many symptoms, from the asymptomatic to the most complicated, and its management remains controversial. Moreover, in the last years many new publications show that this surgery can be perfectly accomplished with the thoracoscopic approach as an alternative to the tradicional open surgery. In this paper we analyse our experience in performing lobectomies with thoracoscopy. This technique shows to be safe and has less complications than tradicional thoracotomy. Methods. During the period 2004-2008 lobectomies were performed in six patiens, with ages between one week and fifteen years. The diagnostics where CAM in four cases, associated to PS in one case; broncogenic cyst in none case, and cavitary pulomonar aspergilloma in one (..) (AU)

[Thoracoscopic lobectomy in pediatrics. Our experience and new treatment perspectives]. / Lobectomía por toracoscopia en pediatría. Nuestra experiencia y nuevas perspectivas de tratamiento.

OBJECTIVES: Pulmonary malformations in the child are a wide clinical and pathologycal spectrum. The congenital cystic adenomatoid malformation and the pulmonary sequestration both produce many symptoms, from the asymptomatic to the most complicated, and its management remains controversial. Moreover, in the last years many new publications show that this surgery can be perfectly accomplished with the thoracoscopic approach as an alternative to the tradicional open surgery. In this paper we analyse our experience in performing lobectomies with thoracoscopy. This technique shows to be safe and has less complications than tradicional thoracotomy. METHODS: During the period 2004-2008 lobectomies were performed in six patiens, with ages between one week and fifteen years. The diagnostics where CAM in four cases, associated to PS in one case; broncogenic cyst in none case, and cavitary pulomonar aspergilloma in one case. RESULTS: Five inferior and one median lobectomies were done. In two cases the patients had no symptoms before intervention, the other four cases were asymptomatic. In all cases the toracoscopy was performed with 3 or 4 ports of 3-5 mm. No mini-thoracotomy was done in any case. There were nor intraoperatory neither postoperatory complications. In all patients were placed two thoracic drainages, being retired 3 to 4 days later. All patients, except one, remained five days in hospital. CONCLUSIONS: In this work, thoracoscopic lobectomy is confirmed as safe technique and with less complications and morbidity than the open lobectomy. Therefore, we suggest new posible aplications.

Estudio comparativo de toracoscopia versus toracotomía en atresia esofágica / Comparative study of thoracoscopy versus thoracotomy in esophageal atresia

Introducción. El abordaje toracoscópico de la atresia de esófago ha sido descrito, pero no existen estudios que muestren sus beneficios con respecto a la técnica abierta tradicional. El objetivo de este estudio es comparar el resultado de la atresia esofágica con fístula traqueoesofágica distal (tipo III) en función del tipo de abordaje. Material y métodos. Entre enero de 2000 y diciembre de 2006 se operó a 31 niños, 17 por toracotomía (peso entre 1.750 y 4.020 g) y14 por toracoscopia (peso entre 1.600 y 4.160 g). Se excluyeron los pacientes que fallecieron por otras patologías (3 casos en el grupo detoracotomía), así que se analizaron 14 pacientes en cada grupo. Las variables estudiadas incluyen: duración del procedimiento quirúrgico, tiempo bajo ventilación mecánica, tiempo con drenaje torácico, tiempo de estancia en cuidados intensivos, momento de inicio de la alimentación oral, duración de analgesia con morfina, tiempo de estancia hospitalaria y porcentaje de complicaciones. Resultados. La necesidad de opiáceos fue superior en el grupo detoracotomía que en el grupo de toracoscopia (media 6,6 días frente a5,3 días, respectivamente, p=0,16). La duración de la hospitalización fue también superior en el grupo de toracotomía (media 22,6 días frente a 19,1 días, p=0,3). No se encontraron diferencias estadísticamente significativas entre ambos grupos respecto a la estenosis de la anastomosis que precisó dilatación (21% en el grupo de toracotomía frente a21% en el grupo de toracoscopia) ni respecto a la indicación de funduplicatura tipo Nissen (28% en el grupo de toracotomía frente a 14%en el grupo de toracoscopia). Conclusiones. El abordaje toracoscópico de la atresia esofágica tipo III reduce tanto la necesidad de analgesia como la duración de la estancia hospitalaria, sin incrementar el riesgo de complicaciones postoperatorias (AU)

Introduction. Thoracoscopic treatment of esophageal atresia type3 has been previously reported to be feasible but no study clearly showed the benefits of thoracoscopy compared to open procedure. The aim of this study was to compare the outcome of esophageal atresia type IIItreated by thoracoscopic or open procedure. Material and method. From january 2000 to december 2006, 31children were operated, 17 by thoracotomy (weight range from 1,750to 4,020 g) and 14 by thoracoscopy (weight range from 2,110 to 4,160g). Neonatal deaths from an independent condition (3 cases in thoracotomy group) were excluded from the study and we analyzed 14 children in each group. Analyzed data included length of surgery, length of postoperative assisted ventilation, length of pleural drainage, length of stay in ICU, delay before oral feeding, length of morphine analgesia, length of hospitalization and rate of complication. Results. Length of morphine analgesia was higher in thoracotomy group than in thoracoscopic group (mean 6, 6 days versus 5,3 days,p= 0,16). Length of hospitalization was also higher in thoracotomy group(mean 22,6 days versus 19,1 days, p= 0,3). The rate of complication with thoracoscopy was not higher need of oesophageal dilatation (21%in thoracoscopic group versus 14 % in thoracotomy group), need of Nissen fundoplication (21 % in thoracoscopic group versus 28% in thoracotomy group).Conclusion. Thoracoscopic treatment of esophageal atresia type III reduces the need of morphine analgesia and the length of stay without increasing the risk of postoperative complications (AU)

[Comparative study of thoracoscopy versus thoracotomy in esophageal atresia]. / Estudio comparativo de toracoscopia versus toracotomía en atresia esofágica.

INTRODUCTION: Thoracoscopic treatment of esophageal atresia type 3 has been previously reported to be feasible but no study clearly showed the benefits of thoracoscopy compared to open procedure. The aim of this study was to compare the outcome of esophageal atresia type III treated by thoracoscopic or open procedure. MATERIAL AND METHOD: From january 2000 to december 2006, 31 children were operated, 17 by thoracotomy (weight range from 1750 to 4020 g) and 14 by thoracoscopy (weight range from 2110 to 4160 g). Neonatal deaths from an independent condition (3 cases in thoracotomy group) were excluded from the study and we analyzed 14 children in each group. Analyzed data included length of surgery, length of post operative assisted ventilation, length of pleural drainage, length of stay in ICU, delay before oral feeding, length of morphine analgesia, length of hospitalization and rate of complication. RESULTS: Length of morphine analgesia was higher in thoracotomy group than in thoracoscopic group (mean 6.6 days versus 5.3 days, p = 0.16). Length of hospitalization was also higher in thoracotomy group (mean 22.6 days versus 19.1 days, p = 0.3). The rate of complication with thoracoscopy was not higher need of oesophageal dilatation (21% in thoracoscopic group versus 14% in thoracotomy group), need of Nissen fundoplication (21% in thoracoscopic group versus 28% in thoracotomy group). CONCLUSION: Thoracoscopic treatment of esophageal atresia type III reduces the need of morphine analgesia and the length of stay without increasing the risk of postoperative complications.

Post-appendectomy intra-abdominal abscesses--can they successfully be managed with the sole use of antibiotic therapy?

PURPOSE: Controversy persists concerning the management of post-appendectomy intra-abdominal abscesses. We hypothesised that most of these abscesses can be successfully managed by antibiotic treatment alone, avoiding the complications of surgical treatment. METHODS: Hospital records of children treated in our unit for intra-abdominal post-appendectomy abscesses over a 6-year period were reviewed retrospectively. RESULTS: This study investigates a series of 26 children from 2 to 15 years of age presenting with one or more post-appendectomy intra-abdominal abscesses. After an average delay of 7 days after initial surgery, 23 children had developed an isolated abscess, while 3 children had multiple abscesses. Twenty-two patients (84.8 %) were treated conservatively by intravenous triple antibiotic therapy alone. Complete clinical, radiological and biological resolution of the abscesses was obtained in all of these children after a mean hospitalisation of 8 days. Four children (15.2 %) were treated surgically: three children with a stable patient status and one child with septic shock requiring urgent surgery. CONCLUSION: The results suggest that intravenous triple antibiotic therapy alone is an efficacious first-line treatment in children developing intra-abdominal abscesses following appendectomy. Surgical intervention is rarely necessary except in patients with an alarming patient status or with signs of septic shock.

[Ultrasonography of fetal esophagus: healthy appearance and prenatal diagnosis of a case of esophagus atresia with esotracheal fistula]. / Echographie de l'oesophage foetal: aspect physiologique et application au dépistage anténatal d'une atrésie oesophagienne.

The thoracic part of a fetal esophagus is generally overlooked by usual prenatal ultrasonography. However, screening it might improve the detection rate of esophageal malformations for which prenatal diagnosis remains far from accurate. In this article, we describe the technique which makes it possible to get a precise image of a fetal thoracic esophagus in its more sensitive part: between the trachea and the aorta. After describing the appearance of a healthy thoracic esophagus, we will show how this technique can be used for prenatal detection of esophagus malformations. For this purpose, we provide the case report of a prenatal diagnosis of esophagus atresia with esotracheal fistula.

Early laparoscopic Kasai's procedure in a low weight newborn.

The authors present an early laparoscopic treatment in a newborn with biliary atresia. They describe the technical details of the Kasai laparoscopic procedure. A 10-day-old girl, weight 2.4 kg, was admitted with a history of jaundice and fecal acholia since birth, with elevated total bilirubin and abnormal hepatic test. Abdominal ultrasound showed a small gallbladder with hyperechogenicity in porta hepatis and absence of biliary principal duct. Other metabolic and hematological tests were normal. The procedure was performed at 20-day-old by laparoscopy. The cholangiography confirmed the biliary atresia and Kasai's procedure was continued by laparoscopy and transumbilical extracorporeal Roux-Y approach. The duration of the procedure was 220 min, with good tolerance of pneumoperitoneum due to the laparoscopy. Feedings of breast milk began on the third day postoperative, presenting normal colored stools, with normalization of the hepatic test. A 20 months follow-up was without complications.

[Pleural empyema in children: Montpellier's experience]. / Les pleurésies purulentes de l'enfant: expérience montpelliéraine.

OBJECTIVES AND METHOD: To assess the management of pleural empyema in pediatric from a medical and surgical experience and a review of the literature. STUDY: Fifty-eight cases were reviewed from January 98 to December 2003. 62.6% have already received antibiotherapy. Forty-three percent of cases were less than three years old. Initial cultures identified Streptococcus pneumoniae in 39%, Streptococcus pyogenes in 5.6%, Mycoplasma pneumoniae and Staphylococcus aureus in only one case and were negative in 47%. A primitive or second-line thoracoscopy were used for drainage in two-third of the cases and mainly 6.95 days after admission. Located pleural empyema and major collected volume were the main indications for thoracoscopy. Three cases have been converted into open thoracotomy. One death occurred in an immunocompromised child. All patients were well at last follow-up. DISCUSSION: The frequency of parapneumonic empyema has increased since ten years. Progress of echography and endoscopy changed their management. Antibiotics have to be effective against pneumococcal infection. Chest tube drainage is necessary to assure the lung reexpansion in case of fibropurulent collection. The difficulty is to optimise the time of video-assisted thoracoscopy (VAT) using predictive criteria as loculations and pneumatoceles. VAT allowed the aspiration of pleural fluid and removing of fibrinous loculations. Moreover VAT achieved optimal adhesiolysis and the irrigation or decortication of the pleural cavity. VAT minimized duration of stay, of chest tube drainage and the indications of thoracotomy.

Thoracoscopic repair of H-type tracheoesophageal fistula in the newborn: a technical case report.

H-type tracheoesophageal fistula (H-TEF) without esophageal atresia makes up 4% to 5% of esophageal congenital abnormalities. The authors present the thoracoscopic treatment of a 2.47-kg newborn boy with a fistula between the second and third thoracic vertebrae diagnosed by esophagography. Four trocars were used for fistula closure, and tracheal and esophageal suturing were accomplished without intraoperative incident. Five days after surgery, results of a barium swallow excluded anastomotic leaks. The chest tube was removed, and oral feeding was initiated.

[A comparative study of the feasibility and limits of ambulatory surgery in infants under and over one year of age]. / Etude comparative de la faisabilité et des limites de la chirurgie ambulatoire chez le nourrisson et chez l'enfant de plus d'un an.

OBJECTIVE: Outpatient surgery in pediatrics is attractive for several reasons. Although 6-8 months has been generally acknowledged as the lower age limit, no minimal age has been clearly established. This study evaluated the outcomes and limits of outpatient surgery in infants from 4 months to 1 year of age. MATERIAL AND METHODS: Between 1996 and 2003, 935 patients were admitted to our hospital for outpatient surgery; of these, 152 were between 4 months and 1 year (mean: 6 months). The indications were essentially surgery to the external genitalia and surgery to remove hernias. The following were exclusion criteria: age below 4 months, ASA scores equal to or above 3, and premature birth with either respiratory distress syndrome or a near-miss of sudden death. RESULTS: More than 98% of the infants met the criteria for outpatient surgery. Cancellations (1.97 vs. 0.51%, P > 0.05), conversions to classic hospitalization (0.65 vs. 0.37%, P > 0.05), postoperative complications (0.65 vs. 0.25%, P > 0.05), rehospitalization (0.65 vs.0.25%, P > 0.05) and relapse of the initial pathology (0.65 vs. 0.63%, P > 0.05) were not more frequent in these infants than in infants over 1 year. CONCLUSION: Pediatric outpatient surgery can be proposed from the age of 4 months without increasing the postoperative risk, either anesthetic or surgical, included for selected former premature infants.

Ideal timing of thoracoscopic decortication and drainage for empyema in children.

BACKGROUND: Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing. METHODS: Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h). RESULTS: In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures. CONCLUSIONS: Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.

Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases.

BACKGROUND: This study aimed to evaluate the optimal conditions for laparoscopic management of neonatal subacute volvulus with malrotation. METHODS: Between 1994 and 2002, 13 neonates with midgut volvulus and malrotation entered the authors' institution. Five of these neonates met the eligibility criteria for laparoscopy: good hemodynamic parameters, no gut perforation, and no severe ischemic distress of the bowel shown on preoperative ultrasonography. RESULTS: The results were excellent for only three infants, associated with a shorter postoperative course. One underwent reoperation for a residual duodenal band, and one conversion to open laparotomy was necessary. The predictors of success were no difficulty identifying the abnormal anatomy, no important chylous stasis, and the learning curve of the surgeon. CONCLUSIONS: Despite its previously reported feasibility, neonatal laparoscopy for volvulus with intestinal malrotation is appropriate only for a small number of patients. Strict selection criteria with a clear understanding of the optimal conditions for success may improve the outcome.

Blunt traumatic injuries of the gastrointestinal and biliary tract in childhood. Analysis of 16 cases.

BACKGROUND: Little attention has been given to abdominal hollow viscus injuries in pediatric literature. The purpose of this report is to describe their main features, and the current methods of diagnosis and treatment. METHODS: We reviewed our experience with 16 cases of blunt injuries involving the gastrointestinal (GI) and biliary tract in the last seven years. RESULTS: Male to female ratio was 0.68 and mean age 9.4 years. The site of injury was the stomach in 2 cases, duodenum in 5, jejunum or ileum in 7, caecum in 2, left mesocolon in 2, and gallbladder in 1. Diagnosis of the 8 perforations was clinically suspected in 6, and confirmed by radiography in 6 or surgery in 2, with a mean delay of 0.42 days. Diagnosis of the 11 hematomas was clinically suspected in 6, and confirmed by radiography in 9 or surgery in 2, with a mean delay of 12.6 days. Hematomas were managed nonoperatively, and perforations were surgically or laparoscopically closed. Mortality was 1/16 by pancreatic injury, and morbidity was 4/16. CONCLUSION: Incidence of blunt hollow viscus injuries is low in children. Hematomas are easily recognized by modern radiography, and simply managed nonoperatively. Diagnosis of perforations still remains difficult. This results in dangerous delays for lesions which need prompt repair.

Evaluation of 142 consecutive laparoscopic fundoplications in children: effects of the learning curve and technical choice.

PURPOSE: This retrospective study describes the 5-year experience of a single surgeon with 142 consecutive laparoscopic fundoplications in children and analyzes the results in terms of the surgeon's learning curve and the choice of technique. METHODS: The patients were 44 girls (40%) and 98 boys (60%) with an age range of 3 months to 18 years (mean, 5.35 years). Indications for surgery included medically refractory reflux associated with vomiting, pneumopathy, otorhinolaryngologic pathology, failure to thrive, esophagitis, apnea and bradycardia, or anemia. The laparoscopic surgery used 5 trocars of 5 mm or 3 mm, with a 30 degrees telescope. RESULTS: Laparoscopic fundoplication was successful in 139 cases. The authors performed 13 Nissen techniques without short gastric vessel division (SGVD), 47 Toupets without SGVD, 9 Toupets with SGVD, and 70 Nissens with SGVD. Mean operating time was 105 minutes (range, 45 to 300). Mean time was 125 minutes for the first 60 cases and 93 minutes for the other 79 cases). Intraoperative and postoperative complication rates were 0.5% and 2%, respectively, and the complications occurred in the first 60 cases. Mean postoperative hospital stay was 3 days (range, 2 to 14). CONCLUSIONS: The rate of complication caused by the laparoscopic procedure was acceptable, and it decreased with the surgeon's experience. Complications and conversions to open technique occurred only in the beginning of the operator's experience. Dysphagia, epigastric pain, gas bloating, and early reflux recurrences were noted among the first 60 cases but seemed to be consecutive to the fact that the gastric vessels were not divided. J Pediatr Surg 36:921-926.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.