To assess the relation of orifice orientation to recorded pressure within the lower esophageal high pressure zone (HPZ) in children, studies were performed on 12 normal subjects. Pressure was measured using a 3-lumen polyvinyl catheter. The lateral orifices of this catheter were uniformly spaced at every 120°interval at the same level of the circumference of the catheter. The catheter was continuously perfused with water by a constant infusion pump at the rate of 30 ml per hour. Resting pressure was recorded at the appropriate level by withdrawing the catheter from the stomach to the esophagus. There was a striking difference in these three recordings at the site of the entry into the HPZ, the point of the maxinum pressure of the HPZ, the maxinum pressure of the HPZ, and the total length of the HPZ, except the exit from the HFZ. The overall results of this study indicate clearly that the lower esophageal HPZ in children is not located in symmetrical position, and a catheter with side hole dose not record the overall intraluminal pressure within HPZ.
Inflammatory process on the hepato-biliary system is suspected to have an important role on the pathogenesis of biliary atresia, neonatal hepatitis and bile duct dilatation (infantile obstructive cholangiopathy). Experimental study on the pathogenesis of infantile obstructive cholangiopathy was performed and the result gave a new concept on the pathogenesis of the diseases. 1, 4-phenylenediisothiocyanate (P.D.T.) was given to five groups of rats of different developmental stages including fetus. The change of the hepato-biliary system in each group was investigated histo-pathologically. All rats in these three groups from newborn to mature, that received P.D.T. after birth, showed characteristic dilatation of the extrahepatic bile ducts with inflammation. One group of rats, receivingP.D.T. during late fetal period, showed only thickening and fibrosis of the wall of the extrahepaticbile ducts without dilatation. The remaining one group of rats, receiving P.D.T. during fetal periodand on thirty days after birth, showed stenosis or obstruction of the ductal lumen due to progressive fibrosis and thickening of the extrahepatic bile ducts. This experimental result suggests that thedifference of the pathologic feature of infantile obstructive cholangiopathy may be the result ofvarious developmental stages of the pathogenic process.
Between 1962 and 1979, 29 patients of Wilms' tumor were treated in the Pediatric Surgical Department and Second Surgical Department, Chiba University, School of Medicine. Eleven were male and 18 female. In 17 patients, the right kidney was involved, in 7 the left, in 4 the bilateral, and in 1 patient the origin was extra renal. Eleven patients have survived without tumor to date, of whichsix have survived over 5 years. In 25 patients, it was possible to examined the involved kidney tissue. Each kidney was sectioned at least at 3 sites and the specimens were stained with Hematoxyline Eosinand Elastica van-Gieson. The vascular invasion was carefully studied histologically. In 7 patient with and 5 without pulmonary metastasis, the vascular invasion of the tumor in the kidney was preciselyexamined by serial section technique. The results were as follows: 1) Histological vascular invasionwas classified into 3 grades : v-0 without any invasion, v-1 with tumor cells observed in the capillaries of the kidney tissue and v-2 with tumor invations in the venules of the porta renalis. that isthe interlobar vein of the kidney. This grading correlated with 1) differentiation rate which was measured by the ratio of the volume of the gromerular and the tubular structures, 2) infiltration rateinto the normal kidney tissue and 3) metastatic rate to the lungs. The histological examination of vascular invasion seemed to be very important for predicting the future development of lung metastasis. 2) Histological examinations on vascular invasion must be performed on the central sagital section of the normal kidney, including the renal pelvis and the porta renalis. The serial section revealed presence of vascular invasion both in continuous and/or interrupted fashion for each patient. 3) The venules near the renal pelvis, that is the interlobar vein, had the significantly more occurrenceof vascular invasion. In the histological examinations, this site must be carefully observed. 4) Patients with pulmonary metastasis had the significantly more occurrence of vascular invasion. However,those with unfavorable factors of NWTS had more susceptibility of pulmonary metastasis. 5) If the occurrence rate of vascular invasion was followed to the Poisson' distribution statistically, the specimen in a patient with unfavorable factor must be examined with at least 30 sections and in others with at least 10 sections, for ruling out the presence of vascular invasion.
Cardiac performance was investigated for cardiac output by Thermodilution method (EDWARDS Model 9510 Cardiac Output Computer and Swan-Ganz Thermodilution Catheter) in 30 VSD and 15 TOF in children under 6 years of age. Cardiac Index (C.I., 1/min/m^2, mean±S.D.) at 4, 8, 12, 24, 48 hours afterOpen-Intracardiac surgery was 3.5±1.4, 3.1±0.9, 3.0±0.8, 3.4±0.8 and 3.8±0.8 1/min/m^2 in VSD group, and 2.6±0.6, 2.3±0.6, 2.2±0.4, 2.4±0.4 and 2.7±0.5 1/min/m^2 in TOF group. In VSD group, cardiac function was poor from 8 to 12 hours after surgery. Therefore, periferal blood circulation was disturbed, and the post-operative complications were likely to occur eary in this period. But after 24 hours, cardiac function was restored. In TOF group, low cardiac output lasted more than 48 hours after surgery, in patients with complications, prognosis was poor. A-VO_2 difference, PVO_2, and deep core temperature difference between Central-Periferal by TERMOFINER CORETEMP were good monitoring techniques for periferal blood circuration and were well coeficient of correlation to Cardiac Output by Thermodilution.
The pelvi-ureteric stenosis (PU stenosis) is not uncommon in pediatric urology. Recently the conservative plastic operation is justified, but the choice of operative procedure is difficult at times. The purpose of this study is to observe histological changes of the kidney in PU stenosis to compare the morphologic findings with clinical data and prognosis. Renal biopsy specimens obtained from 32 children with hydronephrosis were examined. The light microscopic findings of the specimens were classified and scored according to the change in the renal interstitism, renal tubules and bloodvessels. The total score of each subject was designated as "Index of renal histologic alterations". The results were as follows: 1) Tne maturation of the glomerulus or nephron was not delayed or disturbed. 2) No renal dysplasia was found in the specimens. 3) In the group of giant hydronephrosis, moderate or severe change of the kidney structure was found in about half of the children, while in non-giant group, normal or slight alterations accounted for 80%. 4) Urinary tract infection was presentin over 70% of patients. Insidions infection was not uncommon. 5) When the biopsy specimen shows high Index of histologic alterations, one must be carefull of the persistent infection or urographic deteriorations. Our histologic examination of the kidney with PU stenosis in children revealed the relatively well preserved parenchyma. This evidence encouraged us to proceed the conservative plastic operation.
Extrophy of the cloaca is the complex malformation including extrophy of the bladder and the intestine, imperforate anus and the absence of most part of the colon. We have experienced a very rare type of extrophy of the cloaca, characterized by duplication of the colon and the appendix. The patient was associated with omphalocele, short colon, short small bowel, multiple cysts of the rightkidney, complete obstruction of the right ureter, right hydroureter, separated pubis, bilateral clubfoot and duplication of colon and of appendix. Fourty three cases have ever been reported in Japanene literatures scince Kumano's report in 1934. But, there has been no patient with duplication of thecolon.
A 5-year-old girl was admitted because of a lower abdominal tumor of about fist size. A solid ovarian tumor was suspected preoperatively. On laparotomy, it was found a tumor originated from left ovary with an invasion to the uterus to occupy the pelvic cavity. The right ovary and the tube were directly adhered to the surface of the tumor. Resection of the tumor including the uterus, right ovary and salpinx was perfomed with a total omentectomy where the lymph nodes swelling was noted. The resected tumor was about 12X8X7cm, 370g and was typical dysgerminoma histopathlogically. Co-60 radiation was begun on 7th postoperative day by Moving-Strip technique. This patient has been followed up for about 2 years and 3 months and presents with no recurrence to date. This patient seems to be oneof the youngest ones with dysgerminoma reported in Japan.
A fifteen day old baby underwent a Ramstedt's procedure for hypertrophic pyloric stonosis, At operation, a small tumor in the hypertrophic pyloric muscle was found at the contralateral side of the myotomy. The tumor was excised without perforation of the mucus memmbrane. Histologically, the tumor was adenomyoma. The postoperative course was uneventful. It is suspected that these diseases have no interrelationship each other. Extirpation of the adenomyoma without resection of pylorus is thechoice of procedure. This combination seems the first in literature.
Congenital esophageal atresia with congenital stenosis in the distal esophagus has been rarely reported. Two cases with congenital esophageal atresia of Gross A type with congenital esophageal stenosis due to tracheobronchial remnant are reported in this paper. Case 1: A female newborn with congenital esophageal atresia of Gross A type, underwent a gastrostomy. X-ray examination suspected stenosis in the lower esophagus. At esophageal reconstruction with a colon segment at the age of 9 months, an induration of the esophageal wall 2 cm oral from esophagogastric junction was found. Histologic examination of the lower esophageal segment revealed trancheobronchial remnant. Case 2: A 5-day-old female newborn underwent a gastrostomy for congenital esophageal atresia of Gross A type. An X-ray examination revealed lower esophageal stenosis. At the age of 9 months, esophageal reconstruction was performed similarly as in Case 1. Histologic examination of the lower esophageal segment showed the mucous glands and pseudocolumnar ciliated epithelium. Eight cases of congenital esophageal atresia with congenital esophageal stenosis due to tracheobronchial remnant were reviewed from literature, including one reported previously from our Hospital. Among 10 cases including two of our present study, 6 underwent esophageal reconstruction. X-ray examination of lower esophagus prior to radical operation and sham feeding as preoperative management seem to be important in the patient with congenita esophageal atresia of Gross A type with congenital esophageal stenosis.
A 22 month old girl of sacrococcygeal yolk carcinoma is reported. She was admitted with a painful mass in the buttock region. She died of the tumor 11 months after the admission, in spite of 2-staged operation and post-operative irradiation (10,000 rads), chemotherapy (VCR, MMC, CPA) and immunotherapy (OK-432 etc.). At autopsy, there were wide infiltration and multiple distant metastases of yolk sac carcinoma in and around the retroperitoneal space extending to the back and the pleular cavities. Such macroscopic apperances, as well as histological findings, suggested no effectiveness of radio-chemo-immunotherapy in this case. We could successfully culture the yolk sac carcinoma obtaine from the operatively resected specimen. Using the sub-cultured cells following trypsinization, we performed anti-tumor drug sensitivity test, radio-sensitivity test and cytotoxicity test by mixed lymphocyte-tumor cell cultured method. Following results were obtained. 1) Only high doses of MMC and VCR showed moderately sensitive responses. 2) After 72 hours of tissue culture following one shot irradiation of 50 to 1,400rads of 60^Co., almost all tumor cells were visible and growth rate was virtually unchanged. 3) No remarkable cytotoxicity response was noted by mixed patient's lymphocyte-tumorcell culture method. The results obtained from the studies related to tissue culture showed a significant coincidence with clinical course and autopsy findings. These clinical and laboratory results suggested that an ealier diagnosis and an ealier operation are most important for the treatment of sacrococcygeal yolk sac carcinoma. Otherwise post-operative radio-chemo-immuno-therapy might be in-effective to reduce the residual tumor or to prevent recurrence.
A three year-old girl with atrial septal defect, mitral regurgitation and pulmonary edema underwent suture closure of the atrial septal defect and mitral valve replacement with a 23 mm Hancock xenograft on an emergency basis. Relief of symptom was remarkable. Two years later, a grade 2/6 diastolic rumbling murmur was noted at the apex, but her physical activity was normal. She started to have symptom after acute onset of pneumonia 3 years after operation. She was admitted with the diagnosis of mitral stenosis and congestive heart failure 3 years and 4 months after operation. The chest X-ray film showed cardiomegaly (CTR 63%) and pulmonary venous congestion. Echocardiography failed to demonstrate any significant pathology of the porcine xenograft. Cardiac catheterization revealed typical mitral stenosis. The mitral valve area was 0.34cm^2 and the left ventricular ejection fraction was 0.43. The left atrium and the pulmonary artery were dilated. Because of progressive symptom, surgical intervention was indicated. At re-operation, two of the three leaflets of the porcine xenograft were heavily calcified and not mobile, the remaining leaflet was mobile without significant calcification. The porcine xenograft was replaced with a 27mm Bjork-Shiley mitral prosthesis. The patient could not be weaned off bypass because of severe left ventricular failure. Recently, increasing number of reports dealt with high incidence of calcification of the porcine xenograft in children. The increased calcium turnover in children, along with relatively low blood flow through the mitral valve, immunological reaction and fatigue are considered as causes of calcification. Since porcine xenograft posseses high possibility of malfunction in early stage, its application on children should be avoided.
Mesenteric cyst is a rare abdominal tumor in infancy and childhood. The first case was reported by Benevieni in 1,507 and there were now more than 750 cases found in the foregin and 282 cases in the Japanese literatures. A four year old boy was admitted with severe abdominal pain, abdominal distension and vomiting. A laparotomy disclosed a multilobular mesentric cyst with intracystic haemorrhage, which was located near the terminal ileun. The cyst was resected with a part of the ileum and the ileum was anastomosed. Based on the pathological findings of the resected specimen, the pathogenesis of the cyst was discussed.
Although it is rare, renal and peri-renal abscess should be considered when a child spikes fever of unknown origin and/or flank mass. Diagnostic difficulty of renal and peri-renal abscess can be overcomed by the combination of intravenous pyelography, ultrasonography and computed axial tomography. Change in pathogenic organism from classical staphylococcus to gram negative bacilli or fungi was verified. Surgical intervention is mandatory when clinical response to intensive chemotherapy is poor. Based on our experience of three cases with literal review, diagnosis and treatment of renal and peri-renal abscess were discussed.
One hundred twenty-three pediatric cases with panperitonitis were treated at the Pediatric Surgical Department, Chiba University Hospital during the period of January 1973 through December 1979. The organisms, which were isolated at the operation, were E.Coli 67%, Bacteroides fragilis 49%, Klebsiella 32%, Enterococcus 15%, Pseudomonas aeruginosa 14%. Aerobic organisms were isolated in the cases with perforation of the upper gastrointestinal tract, on the other hand, aerobic gram negative rodds and anaerobic Bact. fragilis were isolated in those with lower intestinal tract perforation. The isolation rate of Anaerobic organisms in perforation of the alimentary tract was 12% in stomach, 12.5% in duodenum, 12.5% in jejunum, 28% in ileum, 82% in appendix, and 58% in colon. The isolated organisms from blood cultures were all aerobic gram negative rodds and all but one child of this group died. Aerobic gram negative rodds and anaerobic Bact. fragilis were isolated from the postoperativd infectious lesions. Bact. fragilis was isolated in 8 among 10 cases of the intra-abdominal abscess. Aerobic gram negative rodds, especially Pseudomonas aeruginosa, had resistance against Penicillin & Cephalosporin, but susceptible to Aminoglycoside (Gentamicin, Tobramycin, etc.). Aerobic gram positive Enterococcus was completely susceptible to ABPC. Anaerobic Bact. fragilis was resistant to Aminoglycoside, PC and Cephlospolin, but was susceptible to Chloramphenicol, Lincomycin and Clindamycin. The result of this study leads a conclusoon that the combination of ABPC & Aminoglycoside is the most effective chemotherapy in cases of perforation of the upper gastrointestinal tract, and the combination of Aminoglycoside & Lincomycin in those of the lower intestinal tract.
Questionaire, designed regarding the technique of alimentary tract anastomosis, was sent to 200 Japanese pediatric surgeons and 144 (71.3%) answers were obtained. For esophago-esophagostomy, one layer anastomosis (59) is most popular, secondly the Haigt type procedure (33) and thirdly two layer anastomosis (16). For duodeno-duodenostomy, one layer on the posterior and two layer suture on the anterior wall is adovocated by 69 surgeons. One layer anastomosis and two layer anastomosis on the both anterior and posterior walls (30 and 23 respectively) are also adopted. For high jejuno-jejunostomy, end-to-back anastomosis is popular. One layer anastomosis is used by 49 surgeons and two layer anastomosis by 69. Plasty of the dilated proxymal pouch is controversial. For ileo-ileostomy in newborn, special type of anastomosis such as Halsted, Gambee, vertical mattress or others are attempted by 10 surgeons. However classical two layer anastomosis is still most preferred. Autosuture device (GIA) is preferred by 30 surgeons when along side-to-side anastomosis such as Martin's operation is performed. In general, silk is the most popular suture material. Dexon, Tevdec and cutgut are also used. 5-0 suture is used in the most occations.