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For a period of 32 months from the inception of the Parenteral and Enteral Nutrition (PEN) Team at the University of Michigan, the infection rate (IR) related to central venous catheters (CVCs) for total parenteral nutrition (TPN) was prospectively evaluated. Six hundred twenty-two catheters were placed in 377 patients for a total of 9,200 patient days. The length of CVC stay ranged from 2 to 108 days with a mean of 14.5. CVC longevity was longer on units where certification of nurses by the PEN team was mandatory (mean 20.4 days, IR 3.5%) vs comparable units which utilized informal instruction (mean 14.4 days, IR 3.5%). Twenty-two catheters led to patient sepsis for a rate of 3.5%, or 2.39 CVC-related infections per 1000 patient days. The preteam infection rate was 24.0%, as determined by a 6-month prospective study. Infection rates for CVCs used for TPN only and those used for parenteral nutrition (PN) plus blood products, antibiotics, and CVP measurements were identical, 3.5%. The team approach can effectively increase PN catheter longevity and reduce infection rates. Conservative cost accounting of best and worst case scenarios determined a range of $3,700 to $8,900 per episode of catheter sepsis.

Four hundred twenty-six patients with esophageal atresia with or without tracheoesophageal fistula have been primarily cared for at the University of Michigan Medical Center since Cameron Haight's initial experience with this entity. Over the period of observation, the incidence of new cases as well as the number of associated anomalies has remained constant. The long-term survival of these patients has steadily improved over the past half-century from 36% in the pre-1950 era to 84% during the most recent 20 years. Conversely, operative mortality has shown a progressive decline from 56% early in the authors' series to 6.9% more recently, despite a steady increase in the proportion of high-risk neonates seen at the University of Michigan Medical Center during this time span. In the last 9 years, there have been no postoperative deaths in group A or B risk infants (36 patients), while the rate has been 18.2% in group C risk babies (27 patients); almost all of these deaths were due to severe associated anomalies. During the last 10 years, the authors have changed their technique of anastomosis from a two- to a one-layer method while still advocating a primary repair via an extrapleural approach. Although this change has resulted in a modest increase in the rate of anastomotic leak (17% vs. 6.2%, p less than 0.03), the leaks have been small and asymptomatic because of the extrapleural approach and, as a result, have been managed conservatively without any untoward sequelae. Conversely, there has been a significant decrease in the rate of stricture formation with the one-layer anastomosis (4.3% vs. 23.3%, p less than 0.002). While this may in part be explained by the change in anastomotic technique, it is felt that the more aggressive diagnosis and surgical management of gastroesophageal reflux (seen in 37.9% of our recent group) have contributed greatly to this decrease. The steady improvement in survival over this 50-year period, in spite of the increasing number of high-risk infants, is attributable to major improvements in neonatal care before, during, and after operation.