ObjectiveThe authors determined whether Meckel's diverticulum, discovered incidentally at operation, should be removed. Summary Background DataIt is not clear from the medical literature whether the risk of an incidental Meckel's diverticulectomy is greater than the risk of leaving the diverticulum in place. MethodsThe authors used the medical experience of Olmsted County, Minnesota residents for the period 1950 to 1992 to answer the question. ResultsDuring the period, 58 residents developed Meckel's complications that required diverticulectomies. The incidence of complications was 87 per 100,000 person-years, and the lifetime risk (to 80 years of age) of developing them was 6.4%. The risks were similar throughout the period and at all ages of life, but were greater among men (124 per 100,000 person-years) than women (50 per 100,000 person-years, p < 0.05). Diverticulectomies for complications carried an operative mortality and morbidity of 2% and 12% and a cumulative risk of long-term postoperative complications of 7%, whereas incidental diverticulectomies done in 87 residents during the period carried corresponding rates of only 1%, 2%, and 2%, respectively. ConclusionsMeckel's diverticula discovered incidentally at operation should be removed for most patients, regardless of age.Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, affecting 2% of the general population.1 2 Although this prevalence fig-

Use of a central venous access device (CVAD) can facilitate early introduction of home-based infusion of factor concentrate for long-term prophylaxis or immune tolerance therapy in children with bleeding disorders. The aim was to review outcomes associated with use of CVAD. Retrospective review of paediatric patients with bleeding disorders was observed at the Mayo Clinic Comprehensive Hemophilia Center. Thirty-seven CVAD were placed in 18 patients (haemophilia A [n = 15], type 3 von Willebrand disease [n = 2] and haemophilia B [n = 1]). Follow-up was for 45 952 CVAD days, and median time that CVAD remained in place was 1361 days per device. Factor VIII (FVIII) inhibitors were present in 4 of the 15 patients. Ten CVAD-related infections occurred (median, 672 days; range, 72-1941 days), of which six were in one patient with FVIII inhibitors. Overall infection rate was 0.22 (95% confidence interval [CI], 0.10-0.40) per 1000 CVAD days, with 0.11 infections in patients without FVIII inhibitors compared with a pooled incidence of 0.66 (95% CI, 0.44-0.97) reported in the literature. Indications for removal of 27 CVAD were blockage, change to peripheral venous access, catheter displacement, infection, leak in the port septum, short catheter and skin erosion. No clinically apparent thrombosis or sequelae of thrombosis were observed. Infection is the most common complication associated with CVAD use and is increased in patients who have inhibitors. The low rate of clinically apparent thrombosis reflects our practice of not screening for thrombosis. The low infection rate reflects our practice of using and reinforcing the aseptic technique.

Circumcision is one of the most common procedures performed in male neonates, but few published reports have described circumcision in patients with bleeding disorders. The aim of this study was to analyse outcomes of circumcision among children evaluated at our institution to determine the extent of complications and to provide guidelines for circumcision management. We searched our patient database for records of children who were followed up at the Mayo Clinic Comprehensive Hemophilia Center from 2000 through 2007 and who had been circumcised. We retrospectively reviewed the medical records to document complications and determine management strategies in this patient population. Of 55 children and young adults identified (median [range] age, 15 years [11 months to 21 years]), 48 patients were circumcised. Indications for circumcision were parental request (n = 45) and medical recommendation (n = 3). Twelve of 21 patients with a known bleeding disorder at the time of circumcision received factor replacement before the procedure. Three of these 21 patients had bleeding complications. Of the other 27 patients, who were diagnosed later in life as having a bleeding disorder, 8 had bleeding complications. The overall incidence of bleeding after circumcision was 23% (11/48). The 23% overall incidence of bleeding complications in our patients with bleeding disorders is comparable to that reported for patients without a bleeding disorder (0.1-35%). Some of our patients had significant bleeding despite adequate factor replacement before and after the procedure. Parents and patients must be aware that bleeding risk is a possibility despite adequate factor replacement for hemostasis.

Background and Aims The aim of this study was to determine an appropriate postnatal management plan for prenatally diagnosed BCM including cystic biliary atresia (BA) and choledochal cyst (CC). Methods From 2002 to 2011, a total of 27 consecutive children with CC were treated at our institute. Eight of our 27 patients with CC were diagnosed prenatally and examined clinically. Of these 8 patients, 2 (Group A) underwent delayed primary definitive surgery after percutaneous transhepatic cholangiodrainage (PTCD), 2 (Group B) underwent early definitive surgery in the neonatal period, and 4 (Group C) underwent delayed primary definitive surgery without PTCD in early infancy. Prenatally diagnosed cystic BA was consisted with 2 of patients with type 1 cystic BA (Group D). Results The operation was difficult for adhesion in Group A. The diameter of the anastomosis in the hepaticojejunostomy was small and anastomotic leakage occurred in one of Group B. In all 2 patients, BA was recognized as final diagnosis at laparotomy and a hepaticojejunostomy was carried out because of correctable type. The pathological findings of liver biopsy revealed slight fibrosis of Glisson's sheath in 6 of 8 CC patients. Severe liver fibrosis presented in one of two in cystic BA patients. Conclusion In symptomatic CC patients, PTCD appears to be indicated only under certain circumstances, and delayed primary definitive surgery should be performed as early as possible thereafter. Clinicians need to be aware of cystic BA and how to distinguish it from CC to avoid inadequate primary surgical intervention.

FIGURE 1. A, Preprocedure electrocardiogram showing monomorphic nonsustained ventricular tachyarrhythmia with superior axis left bundle branch block morphology. B, Postprocedure electrocardiogram showing sinus rhythm and no ventricular arrhythmia.