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Normovolemic hemodilution and intraoperative autotransfusion in children: Experience with 30 cases of spinal fusion
INTERNATIONAL
125
ABSTRACTS
arteries were ligated and divided. Although drains were used in 11 of the 15 patients, the authors did not think that drainage was a causative factor. The authors suggest treatment by drainage, antibiotics, nasogastric suction, H2 blockers. and nutritional support; surgical closure is indicated when the fistula fails to close. Ten of the 15 patients required closure. and 4 of the 15 died.--Sigmund H. Eirl Short-Term and Long-Term Problems After Duraplastic Enlargement of Anterior Abdominal Wall. P. Klein, H.P. Hiimmer, S. Wellert, et al. Eur J Pediatr Surg 1:88-91, (April), 1991. A series of 83 children with gastroschisis or omphalocele is reported, 49 of whom received duraplastic enlargement of the anterior abdominal wall. The solvent dried dura proved to be a most useful material which could be left in place even after a scar had formed. Abdominal complications depended on preexisting intestinal damage and increased intraabdominal pressure. Percentage (20%) and severity of long-term intestinal disturbances were comparable lo other reconstructive methods. Secondary operations were not necessary due to progressive tightening of the scar plate.-T!~rnus A. Angerpointner Congenital Lumber (Grynfeldt-Lesshaft) Hernia. M. Pul, N. Pul, urzd N. C2ir.ce.s.Eur J Pediatr Surg 1:115-117, (April), 1991. Lumbar hernias that occur in the flank are mostly acquired. Two children with congenital superior lumbar hernias are presented. The firs1 child had many associated anomalies and the second had an open myelomeningocele. Both lumbar hernias were repaired without difficulties. Operative repair is recommended before 12 months of age. because the hernial defect may enlarge with growth, making primary closure with surrounding tissue more difficult.Thomas A. .4n~erpointner
GENITOURINARY
TRACT
The Anatomy of the Female Gubernaculum Is Different From the Ma1e.A.E. Attah and J.M. Hudson. Aust NZJ Surg 61:380-384. (May), 19Y I. This article addresses the anatomy of the female gubernaculum. The authors dissected the round ligament in 10 girls (aged 0 to 11 years) dying of nongenital disorders. They clearly demonstrated that the round ligament ended just below the external inguinal ring in all cases and not in the labium majora as is described in most standard anatomy texts. The absence of the migration phase of the gubernaculum, which accompanies and probably controls testicular descent in the male, results in the round ligament ending at the external ring in the female. The authors cite this is as an example of sexual differentiation in the fetus and suggest that the standard anatomy text should be amended.-Prrtricia Davidson Urethral Reconstruction Using an Autologous Bladder Mucosal Graft. J. Schnupka and H. Mildenhetger. Eur J Pediatr Surg 1:180-182. (June), 1991. Reconstruction of the urethra by autologous bladder mucosal graft was performed in 12 children. In 10 of these, previous surgery for hypospadias or other penile anomalies had failed. The patients were between 1 and 14 years of age. The bladder mucosal graft originated from the anterior bladder wall and was shaped into a tube according to the technique described by Hendren. The distal end of the urethra was shaped from preputial skin and anastomosed with the bladder mucosal tube. The authors conclude that urethral reconstruction with bladder mucosal graft is a valuable addition to the available reconstruction methods. It is particularly useful after failed hypospadias repair and even as primary operation in selected cases.-Thomas A. Angerpointner
Two-Step Orchiopexy With Pelviscopic Clip Ligation of the Spermatic Vessels. D.A. Bloom. J Ural 145:1030-1033, (May). 1991. Ten boys with nonpalpable testes located in the peritoneal cavity underwent endoscopic clip ligation of the spermatic vessels with the intent of augmentingvasal collateral blood flow. After intervals in excess of 6 months, seven patients underwent vas-based orchiopexy following division of the occluded spermatic vessels. Six boys had good results as judged by size of the relocated testes. In one boy the testis atrophied. He had undergone previous inguinal-only exploration before referral for celiopelviscopy, and at stage 2 orchidopexy a silk suture was found on the vas deferens.-GeoTe Holcomh, Jr Resolution of Vesicoureteral Reflux in Completely Duplicated Systems: Fact or Fiction? D.A. Husmarm and T D. Alien. J Urol 145:1022-1023, (May), 1991. Sixty patients (71 renal units) with grade 215 vesicoureteral reflux into the lower pole of a completely duplicated system were managed by medical surveillance and are compared with an identically managed age-, race-. and sex-matched control population with a similar degree of reflux into a single collecting system. During a median 2-year observation period, reflux ceased spontaneously in 10% of the patients with duplication compared with 35% of the control population (P < .Ol). Comparisons between the two study groups failed to show a difference in the incidence of break-through urinary tract infections, advancing degrees of reftux. and/or the development or progression of renal scarring (P > 5). Despite the fact that the resolution rate in duplex systems is significantly lower than that of a single system. it is apparent that cessation of grade 215 reflux into a duplicated ureter will occur and that a trial of medical management is an appropriate initial method of therapy.-George Hoicomb, Jr Development of Renal Failure in Children With the Prune Belly Syndrome. Y. Reinberg, J. Manivel. G. Peffmufo. et ul. J Urol 145:1017-1019, (May), 1991. From 1970 to 1987, 32 male and female patients with the prune-belly syndrome were evaluated. Of these patients 11 died as neonates or infants. and autopsy in 9 showed 6 cases of diffuse and severe renal dysplasia. In the 10 surviving patients renal insuficiency developed and a total of 13 nrphrectomies and renal biopsies were performed. Renal dysplasia was noted in 9 specimens, but unlike the infant kidneys, the dysplastic changes involved less than 25% of the parenchyma in most cases. Renal failure in these 10 patients was caused by pyelonephritis and obstruction. In the authors’ opinion, perinatal renal failure in patients with the prunebelly syndrome results from renal dysplasia caused by an in utero insult, whereas in older patients pyelonephritis and obstruction are the causes. Careful treatment of reflux, obstruction. and urinary tract infections may decrease the incidence of renal failure in patients with the prune-belly syndrome who survive infancy.George Holcomh, Jr
MUSCULOSKELETAL
SYSTEM
Normovolemic Hemodilution and IntraoperativeAutotransfusion in Children: Experience With 30 Cases of Spinal Fusion. M. Haberkem alld P. DangeL. Eur J Pediatr Surg 1:X)-35. (February), 1991. Based on 30 cases of ventral and/or dorsal spondylodesia in children and adolescents between 3.4 and 19.Y years of age, this report describes a method for the minimization of homologous blood transfusion. The method consists of extreme hemodilution. combined with mild hypothermia and controlled hypotension. Af-
INTERNATIONAL
126
ter induction of anesthesia, the hematocrit is reduced to 0.20 to 0.25 by withdrawal of blood and replacement with Ringer’s lactate in a 3:l lactate/blood ratio. The blood is retransfused as soon as the hematocrit decreases below 0.12 to 0.14 or at the end of surgery. In 12 cases, an intraoperative blood recovery system (cell saver) was used as additional autotransfusion technique. During hemodilution no acidosis or increase in serum lactate was found. If the hematocrit decreased below 0.20, there was a significant decrease of central venous oxygen saturation attributed to increased tissue oxygen extraction. During the first 12 to 24 postoperative hours all patients showed peripheral edema and massive diuresis with a tendency to hypovolemia. During this period close monitoring on the intensive care unit was necessary. Hematocrit and reticulocyte count normalized within 4 weeks. Compared with an earlier series of spondylodesis, wherein all patients received banked blood, homologous blood transfusion was reduced by about 75%. This was due not only to autotransfusion techniques, but also to painstaking surgical hemostasis and restrictive indications for homologous transfusion.-Thomas A. Angetpointner Open Fractures of the Tibia in Children. S.L. Buckley, G. Smith, P.D. Sponseller, etaI. J Bone Joint Surg (Am) 72:1462-1469, (December), 1990. Forty-one children with 42 metaphyseal and diaphyseal tibia1 fractures were studied retrospectively. The fractures were classified according to the Gustilo classification system. The initial treatment consisted of irrigation and debridement and antibiotics for an ultimate 48 hours of coverage. Twenty-two of the 41 patients initially had external fixation treatment; the remainder were managed in plaster casts. Three patients had early infections. One was associated with an osteomyelitis. Twenty percent of the patients treated with external fixation had pin track infections responding to conservative care. Twenty percent of the patients had ultimate limb length discrepancy with the injured tibia being longer in all patients. Average time to fracture healing was 5 months (range, 2 to 21 months). Delays in healing were associated with increased severity of soft tissue injury, infections, the use of internal fixation, and loss of segments of bone. The course of open tibia1 fractures in children is comparable to that in adults except for the phenomenon of overgrowth.-Anthony H. Alter The Klippel-Trenaunay Syndrome. S. Sooriakumaran and T. La1 Landham. J Bone Joint Surg (Br) 73:169-170, (January), 1991. Klippel-Trenaunay syndrome is a triad of congenital anomalies characterized by a vascular nevus, varicose veins, and hypertrophy of soft tissue and bone. The majority of cases involve a single lower limb and are associated with limb length discrepancy and cosmetic and functional disabilities. Amputation may be required. This report describes four patients who underwent partial lower limb amputations in childhood and documents the stump complications, prosthetic difficulties, and general complications associated with the syndrome. The role of orthopedic procedures in the KlippelTrenaunay syndrome is discussed, and for those rare patients requiring amputation, a through-knee disarticulation is advised.Mark D. Stringer Post-traumatic Compartment Syndrome Bednar. Can J Surg 34:179-181, (April), 1991.
of the Foot. D.A.
Posttraumatic acute compartment syndrome due to ischemia in the foot is well recognized but unusual. This is an interesting case report (only the third one ever reported) involving a 17-year-old
ABSTRACTS
boy who suffered a massive injury to his lower extremity (compound fracture of femur, compound comminuted fracture of tibia with skin and muscle loss, crush injury to foot “with heavy bruising and extensive tense swelling of the soft tissues”). The foot was cool but had sensation; toe movements caused increased foot and calf pain. Pedal pulses were thready. The patient underwent immediate debridement and primary stabilization of both long bone fractures, but the foot became progressively more tense and swollen with capillary refill time of about 3 seconds. Digital transcutaneous oxygen tension through the plantar surface was 50 mm Hg compared with 90 mm Hg on the control (normal) side. Similarly, the intermetatarsal compartmental pressure was 38 mm Hg and the plantar compartment pressure was 68. Following these clinical evaluations, the intermetatarsal compartments were decompressed by two dorsal incisions, and the plantar compartment was decompressed through a long lateral incision using a Kelly forceps. The above surgical decompression decreased the intermetatarsal tissue pressures from 38 to 34 mm Hg and the plantar pressures from 68 to 38 mm Hg. This led to increased tissue decompression blushing and a reduction of capillary refill time from 3 seconds to 1 second; the transcutaneous oxygen tension rose to 92 mm Hg immediately after decompression. Six days later the fasciotomy incisions were closed and total recovery was excellent 6 months later. Interstitial tissue pressure measurements are believed to be much more important than the cutaneous blood flow and oxygenation measurements, because the latter two may be normal in compartment syndromes and, hence, may not rule out underlying compartmental ischemia in a damaged limb.-Sigmund H. Ein
NEOPLASMS Percutaneous Needle Biopsy Preceding Preoperative Chemotherapy in the Management of Massive Renal Tumors in Children. V.M. Saarinen, S. Wikstrom, 0. Koskimies, et al. J Clin Oncol9:406-415, (March), 1991. The authors review the experience of the International Society of Pediatric Oncology (SIOP) with posterior percutaneous needle biopsy in the diagnosis of Wilms’ tumor. The care of seven consecutive patients who underwent such needle biopsies was reviewed. The biopsy proved useful in that two patients with necrotic tumors and two with unfavorable histology were identified preoperatively. Histological evaluation was used to determine preoperative chemotherapy, which was given in all cases and resulted in easier, safer surgery. Complications of this procedure included two subcapsular renal hematomas treated nonoperatively. In conclusion, the authors advocate that in a disease with as good a survival as Wilms’ tumor, preoperative biopsy and preoperative chemotherapy with or without radiotherapy based on histological grading will further enhance survival by promoting safer, more effective surgeiy.-Michael I? Hirsh and Ian T. Cohen Hepatopathy-Thrombocytopenia Syndrome-A Complication of Dactinomycin Therapy for Wilms’ Tumor: A Report From the United Kingdom Childrens Cancer Study Group. J. Raine, A. Bowman, K. Wallendszus, et al. J Clin Oncol 9~268-273, (February). 1991. This study describes the hepatopathy-thrombocytopenia syndrome (HTS) that surgeons seeing postchemotherapy Wilms’ tumor patients may encounter. The children are usually diagnosed within the first 10 weeks of treatment and present with jaundice, thrombocvtopenia, and, in severe cases, elevated transaminases and prothrombin times. HTS usually lasts 10 to 14 days and resolves spontaneously with cessation of chemotherapy. Although Dactinomycin has been found to be the etiologic factor, it can be
125
ABSTRACTS
arteries were ligated and divided. Although drains were used in 11 of the 15 patients, the authors did not think that drainage was a causative factor. The authors suggest treatment by drainage, antibiotics, nasogastric suction, H2 blockers. and nutritional support; surgical closure is indicated when the fistula fails to close. Ten of the 15 patients required closure. and 4 of the 15 died.--Sigmund H. Eirl Short-Term and Long-Term Problems After Duraplastic Enlargement of Anterior Abdominal Wall. P. Klein, H.P. Hiimmer, S. Wellert, et al. Eur J Pediatr Surg 1:88-91, (April), 1991. A series of 83 children with gastroschisis or omphalocele is reported, 49 of whom received duraplastic enlargement of the anterior abdominal wall. The solvent dried dura proved to be a most useful material which could be left in place even after a scar had formed. Abdominal complications depended on preexisting intestinal damage and increased intraabdominal pressure. Percentage (20%) and severity of long-term intestinal disturbances were comparable lo other reconstructive methods. Secondary operations were not necessary due to progressive tightening of the scar plate.-T!~rnus A. Angerpointner Congenital Lumber (Grynfeldt-Lesshaft) Hernia. M. Pul, N. Pul, urzd N. C2ir.ce.s.Eur J Pediatr Surg 1:115-117, (April), 1991. Lumbar hernias that occur in the flank are mostly acquired. Two children with congenital superior lumbar hernias are presented. The firs1 child had many associated anomalies and the second had an open myelomeningocele. Both lumbar hernias were repaired without difficulties. Operative repair is recommended before 12 months of age. because the hernial defect may enlarge with growth, making primary closure with surrounding tissue more difficult.Thomas A. .4n~erpointner
GENITOURINARY
TRACT
The Anatomy of the Female Gubernaculum Is Different From the Ma1e.A.E. Attah and J.M. Hudson. Aust NZJ Surg 61:380-384. (May), 19Y I. This article addresses the anatomy of the female gubernaculum. The authors dissected the round ligament in 10 girls (aged 0 to 11 years) dying of nongenital disorders. They clearly demonstrated that the round ligament ended just below the external inguinal ring in all cases and not in the labium majora as is described in most standard anatomy texts. The absence of the migration phase of the gubernaculum, which accompanies and probably controls testicular descent in the male, results in the round ligament ending at the external ring in the female. The authors cite this is as an example of sexual differentiation in the fetus and suggest that the standard anatomy text should be amended.-Prrtricia Davidson Urethral Reconstruction Using an Autologous Bladder Mucosal Graft. J. Schnupka and H. Mildenhetger. Eur J Pediatr Surg 1:180-182. (June), 1991. Reconstruction of the urethra by autologous bladder mucosal graft was performed in 12 children. In 10 of these, previous surgery for hypospadias or other penile anomalies had failed. The patients were between 1 and 14 years of age. The bladder mucosal graft originated from the anterior bladder wall and was shaped into a tube according to the technique described by Hendren. The distal end of the urethra was shaped from preputial skin and anastomosed with the bladder mucosal tube. The authors conclude that urethral reconstruction with bladder mucosal graft is a valuable addition to the available reconstruction methods. It is particularly useful after failed hypospadias repair and even as primary operation in selected cases.-Thomas A. Angerpointner
Two-Step Orchiopexy With Pelviscopic Clip Ligation of the Spermatic Vessels. D.A. Bloom. J Ural 145:1030-1033, (May). 1991. Ten boys with nonpalpable testes located in the peritoneal cavity underwent endoscopic clip ligation of the spermatic vessels with the intent of augmentingvasal collateral blood flow. After intervals in excess of 6 months, seven patients underwent vas-based orchiopexy following division of the occluded spermatic vessels. Six boys had good results as judged by size of the relocated testes. In one boy the testis atrophied. He had undergone previous inguinal-only exploration before referral for celiopelviscopy, and at stage 2 orchidopexy a silk suture was found on the vas deferens.-GeoTe Holcomh, Jr Resolution of Vesicoureteral Reflux in Completely Duplicated Systems: Fact or Fiction? D.A. Husmarm and T D. Alien. J Urol 145:1022-1023, (May), 1991. Sixty patients (71 renal units) with grade 215 vesicoureteral reflux into the lower pole of a completely duplicated system were managed by medical surveillance and are compared with an identically managed age-, race-. and sex-matched control population with a similar degree of reflux into a single collecting system. During a median 2-year observation period, reflux ceased spontaneously in 10% of the patients with duplication compared with 35% of the control population (P < .Ol). Comparisons between the two study groups failed to show a difference in the incidence of break-through urinary tract infections, advancing degrees of reftux. and/or the development or progression of renal scarring (P > 5). Despite the fact that the resolution rate in duplex systems is significantly lower than that of a single system. it is apparent that cessation of grade 215 reflux into a duplicated ureter will occur and that a trial of medical management is an appropriate initial method of therapy.-George Hoicomb, Jr Development of Renal Failure in Children With the Prune Belly Syndrome. Y. Reinberg, J. Manivel. G. Peffmufo. et ul. J Urol 145:1017-1019, (May), 1991. From 1970 to 1987, 32 male and female patients with the prune-belly syndrome were evaluated. Of these patients 11 died as neonates or infants. and autopsy in 9 showed 6 cases of diffuse and severe renal dysplasia. In the 10 surviving patients renal insuficiency developed and a total of 13 nrphrectomies and renal biopsies were performed. Renal dysplasia was noted in 9 specimens, but unlike the infant kidneys, the dysplastic changes involved less than 25% of the parenchyma in most cases. Renal failure in these 10 patients was caused by pyelonephritis and obstruction. In the authors’ opinion, perinatal renal failure in patients with the prunebelly syndrome results from renal dysplasia caused by an in utero insult, whereas in older patients pyelonephritis and obstruction are the causes. Careful treatment of reflux, obstruction. and urinary tract infections may decrease the incidence of renal failure in patients with the prune-belly syndrome who survive infancy.George Holcomh, Jr
MUSCULOSKELETAL
SYSTEM
Normovolemic Hemodilution and IntraoperativeAutotransfusion in Children: Experience With 30 Cases of Spinal Fusion. M. Haberkem alld P. DangeL. Eur J Pediatr Surg 1:X)-35. (February), 1991. Based on 30 cases of ventral and/or dorsal spondylodesia in children and adolescents between 3.4 and 19.Y years of age, this report describes a method for the minimization of homologous blood transfusion. The method consists of extreme hemodilution. combined with mild hypothermia and controlled hypotension. Af-
INTERNATIONAL
126
ter induction of anesthesia, the hematocrit is reduced to 0.20 to 0.25 by withdrawal of blood and replacement with Ringer’s lactate in a 3:l lactate/blood ratio. The blood is retransfused as soon as the hematocrit decreases below 0.12 to 0.14 or at the end of surgery. In 12 cases, an intraoperative blood recovery system (cell saver) was used as additional autotransfusion technique. During hemodilution no acidosis or increase in serum lactate was found. If the hematocrit decreased below 0.20, there was a significant decrease of central venous oxygen saturation attributed to increased tissue oxygen extraction. During the first 12 to 24 postoperative hours all patients showed peripheral edema and massive diuresis with a tendency to hypovolemia. During this period close monitoring on the intensive care unit was necessary. Hematocrit and reticulocyte count normalized within 4 weeks. Compared with an earlier series of spondylodesis, wherein all patients received banked blood, homologous blood transfusion was reduced by about 75%. This was due not only to autotransfusion techniques, but also to painstaking surgical hemostasis and restrictive indications for homologous transfusion.-Thomas A. Angetpointner Open Fractures of the Tibia in Children. S.L. Buckley, G. Smith, P.D. Sponseller, etaI. J Bone Joint Surg (Am) 72:1462-1469, (December), 1990. Forty-one children with 42 metaphyseal and diaphyseal tibia1 fractures were studied retrospectively. The fractures were classified according to the Gustilo classification system. The initial treatment consisted of irrigation and debridement and antibiotics for an ultimate 48 hours of coverage. Twenty-two of the 41 patients initially had external fixation treatment; the remainder were managed in plaster casts. Three patients had early infections. One was associated with an osteomyelitis. Twenty percent of the patients treated with external fixation had pin track infections responding to conservative care. Twenty percent of the patients had ultimate limb length discrepancy with the injured tibia being longer in all patients. Average time to fracture healing was 5 months (range, 2 to 21 months). Delays in healing were associated with increased severity of soft tissue injury, infections, the use of internal fixation, and loss of segments of bone. The course of open tibia1 fractures in children is comparable to that in adults except for the phenomenon of overgrowth.-Anthony H. Alter The Klippel-Trenaunay Syndrome. S. Sooriakumaran and T. La1 Landham. J Bone Joint Surg (Br) 73:169-170, (January), 1991. Klippel-Trenaunay syndrome is a triad of congenital anomalies characterized by a vascular nevus, varicose veins, and hypertrophy of soft tissue and bone. The majority of cases involve a single lower limb and are associated with limb length discrepancy and cosmetic and functional disabilities. Amputation may be required. This report describes four patients who underwent partial lower limb amputations in childhood and documents the stump complications, prosthetic difficulties, and general complications associated with the syndrome. The role of orthopedic procedures in the KlippelTrenaunay syndrome is discussed, and for those rare patients requiring amputation, a through-knee disarticulation is advised.Mark D. Stringer Post-traumatic Compartment Syndrome Bednar. Can J Surg 34:179-181, (April), 1991.
of the Foot. D.A.
Posttraumatic acute compartment syndrome due to ischemia in the foot is well recognized but unusual. This is an interesting case report (only the third one ever reported) involving a 17-year-old
ABSTRACTS
boy who suffered a massive injury to his lower extremity (compound fracture of femur, compound comminuted fracture of tibia with skin and muscle loss, crush injury to foot “with heavy bruising and extensive tense swelling of the soft tissues”). The foot was cool but had sensation; toe movements caused increased foot and calf pain. Pedal pulses were thready. The patient underwent immediate debridement and primary stabilization of both long bone fractures, but the foot became progressively more tense and swollen with capillary refill time of about 3 seconds. Digital transcutaneous oxygen tension through the plantar surface was 50 mm Hg compared with 90 mm Hg on the control (normal) side. Similarly, the intermetatarsal compartmental pressure was 38 mm Hg and the plantar compartment pressure was 68. Following these clinical evaluations, the intermetatarsal compartments were decompressed by two dorsal incisions, and the plantar compartment was decompressed through a long lateral incision using a Kelly forceps. The above surgical decompression decreased the intermetatarsal tissue pressures from 38 to 34 mm Hg and the plantar pressures from 68 to 38 mm Hg. This led to increased tissue decompression blushing and a reduction of capillary refill time from 3 seconds to 1 second; the transcutaneous oxygen tension rose to 92 mm Hg immediately after decompression. Six days later the fasciotomy incisions were closed and total recovery was excellent 6 months later. Interstitial tissue pressure measurements are believed to be much more important than the cutaneous blood flow and oxygenation measurements, because the latter two may be normal in compartment syndromes and, hence, may not rule out underlying compartmental ischemia in a damaged limb.-Sigmund H. Ein
NEOPLASMS Percutaneous Needle Biopsy Preceding Preoperative Chemotherapy in the Management of Massive Renal Tumors in Children. V.M. Saarinen, S. Wikstrom, 0. Koskimies, et al. J Clin Oncol9:406-415, (March), 1991. The authors review the experience of the International Society of Pediatric Oncology (SIOP) with posterior percutaneous needle biopsy in the diagnosis of Wilms’ tumor. The care of seven consecutive patients who underwent such needle biopsies was reviewed. The biopsy proved useful in that two patients with necrotic tumors and two with unfavorable histology were identified preoperatively. Histological evaluation was used to determine preoperative chemotherapy, which was given in all cases and resulted in easier, safer surgery. Complications of this procedure included two subcapsular renal hematomas treated nonoperatively. In conclusion, the authors advocate that in a disease with as good a survival as Wilms’ tumor, preoperative biopsy and preoperative chemotherapy with or without radiotherapy based on histological grading will further enhance survival by promoting safer, more effective surgeiy.-Michael I? Hirsh and Ian T. Cohen Hepatopathy-Thrombocytopenia Syndrome-A Complication of Dactinomycin Therapy for Wilms’ Tumor: A Report From the United Kingdom Childrens Cancer Study Group. J. Raine, A. Bowman, K. Wallendszus, et al. J Clin Oncol 9~268-273, (February). 1991. This study describes the hepatopathy-thrombocytopenia syndrome (HTS) that surgeons seeing postchemotherapy Wilms’ tumor patients may encounter. The children are usually diagnosed within the first 10 weeks of treatment and present with jaundice, thrombocvtopenia, and, in severe cases, elevated transaminases and prothrombin times. HTS usually lasts 10 to 14 days and resolves spontaneously with cessation of chemotherapy. Although Dactinomycin has been found to be the etiologic factor, it can be