We prospectively investigated 100 pediatric patients suffering from phimosis and found a 10% incidence of lichen sclerosus et atrophicus. This condition usually can be diagnosed preoperatively because of its classic manifestation of severe phimosis due to a sclerotic, whitish ring at the tip of the prepuce, which in our cases was accompanied by sclerogenous glanular lesions. To our knowledge our study represents the first evidence that the development of secondary phimosis with no apparent reason in school-age boys is highly suggestive for lichen sclerosus et atrophicus. Complete circumcision is the therapy of choice because it completely removes all affected tissue and it allows spontaneous regression or resolution of glanular lesions. There has been no recurrence after 5 years of followup.

In order to identify possible underlying ganglion-cell disorders, specimens have been taken in neonates and infants with intestinal obstruction treated between January 1988 and June 1992. NID was confirmed in 3 patients with intestinal malformation, 2 patients with neonatal intestinal obstruction, 3 patients with meconium peritonitis, 1 patient with persistent constipation after Duhamel's pull-through for Hirschsprung's disease and 1 patient with rectal stricture after conservative treatment for necrotising enterocolitis. Additionally, NID was found in 1 patient with recurrent prolapse of an ileostomy. Associated Hirschsprung's disease has been ruled out by additional rectal suction biopsies in patients where specimens have been collected at laparotomy first. Development of NID in previous normal bowel, the association of NID with intestinal malformations as well as the clinical heterogeneity of patients with NID of the present series suggest that NID is a reaction of the neural intestinal system caused by congenital obstructive factors or inflammatory diseases.

The rate of Hirschsprung-associated neuronal intestinal dysplasia (HANID) is reported to be as high as 20-75% but no report deals with its sequelae. The aim of our study was to evaluate the influence of the retained neuronal dysplastic segment in patients with Hirschsprung's disease (HD). We report on 47 patients with HD including 11 cases with HANID (23%). All 47 children had a Duhamel procedure subsequent to colostomy and in none of the 11 cases with HANID was the neuronal dysplastic segment resected. There was no significant difference of early and late complications in both groups and the results of the mean follow-up of 5 years after the Duhamel procedure show that the patients with HANID did as well as the patients with isolated HD. It is suggested therefore that HANID may be a distinct disease compared to isolated NID and that the NID attained segment may be retained without increased risks or morbidity.

This is a 15-year retrospective study of 64 pediatric surgical patients with traumatic rupture of the spleen from 1976 to 1990. The overall mortality was 14% (9/64). All non-survivors had severe multiple traumata and no fatalities were attributable to splenic injury. During the first 5 years of the study, the traditional surgical approach of immediate laparotomy and splenectomy was employed. During the next 5 years we practised laparotomy with subtotal splenectomy and repair. During the final 5 years conservative management with clinical and ultrasonographic monitoring became predominant (1 splenectomy, 4 repair, 23 conservative treatments). Among the 55 survivors, 11 had splenectomy, 14 had splenic repairs and 30 were treated non-operatively. All survivors had excellent outcomes and there was only one complication: a local abscess following splenic repair. Based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced remarkably during the last period. Splenectomized patients received pneumococcal vaccine and prophylactic antibiotic coverage was prescribed for febrile episodes. None of the splenectomized patients experienced septic episodes or increased rates of infection. Based on our experience, ultrasonographically monitored conservative management is the treatment of choice in most patients with splenic injury in childhood.

The Nissen fundoplication is the operative therapy of choice in children with symptomatic gastroesophageal reflux. In recent years several reports on specific complications of the Nissen fundoplication have been published. This report summarizes the complications in 45 patients on whom a Nissen fundoplication was performed in our clinic between 1979 and 1989. 18 patients (40%) showed early or late complications. In 10 patients (22%) reoperation was necessary. However, at follow-up with a mean period of 4 1/2 years after surgery, 36 patients (92%) showed good results without any residual symptoms. The Nissen fundoplication had in our hands a rather high rate of complications. However, late results were excellent and our healing rate (92%) was higher than reported in other series with different techniques.