Excretion of intravenously given antibiotics (LMOX and CMZ) into the bile was studied in 16 patients who had had hepatic portoenterostomy with Suruga II type enterostomy for congenital biliary atresia. Excretion of antibiotics into the bile was excellent and almost the same as that seen in adult patients in two cases of Group I (correctable type, jaundice disappeared after the operation). Excretion of antibiotics into the bile was good or poor, depending on the amount of bile flow and liver function in five cases of Group IIa (non-correctable type, jaundice disappeared after the operation). Excretion of antibiotics into the bile was very poor in five cases of Group IIb (non-correctable type, jaundice persisted after the operation). Excretion of antibiotics into the bile was good but variable depending on the amount of bile flow and liver function in four cases of Group III (non-correctable type, jaundice disappeared after the operation, the test was done in the early postoperative period). Results of the present studies indicate that biliary excretion of intravenously given antibiotics is closely related to the condition of the liver function and biliary passage in these patients.
Undescended testis is a common pediatric surgical problem, and in the majority of instances a straightforward orchidopexy with preservation of both the spermatic vessels and the vas is possible. However, with a high undescended testis the spermatic vessels do not have sufficient length to permit a conventional orchidopexy. Staged operation and "long loop vas" operation are the current methods for these cases. There is, however, a relatively high rate of failure after these procedures. To determine the effects of division of the spermatic vessels, 93 rats were divided into four groups according to their weight and position of the testis. Spermatic vessels were divided either at the inguinal canal, or halfway between their origin and the internal ring (abdominal level). The results show that: 1) testis in which the vessels were divided at the inguinal level showed distinct degeneration from infarction one month after the operation or postoperatively, in all group, 2) testis in which the vessels were divided at the abdominal level appeared normal. These results show that division of the vessels at the abdominal level is preferred over the inguinal level in rats.
Endoscopic manipulations including washing of anastomotic site and removal of suture materials and granulation were applied firstly in patients with decreased or failed bile flow after hepatic porto-enterostomy for congenital biliary atresia. For patients who had no sufficient bile flow after such manipulations, removal or resection of the granulation or scar tissue at the hepatic porta was performed. By manipulation and reoperation, the following results were obtained: 1. Endoscopic manipulations led a remarkabl effect in one of nine cases. This procedure was useful to evaluate the indication of reoperation. 2. Of eight reoperations, constant bile flow was obtained in three who had had considerable bile flow temporally after the primary operation and undergone adequate resection of the scar tissue at the secondary procedure. 3. The special scissors divised by us was useful for the resection of the scar tissue.
Our previous studies suggested that net splanchnic production of ketone bodies rose markedly after operation in pediatric surgical patients. For better understanding the results we attempted to investigate the relationship between circulating hormone (insulin, glucagon and growth hormone) levels and blood ketone body. Ketone body, free fatty acid, insulin, glucagon and growth hormone were simultaneously measured in 34 pediatric surgical patients in pre and postoperative days. The hormones were determined by radioimmunoassy, and glucagon was examined using specific antibodies to pancreatic glucagon 30-K. The blood level of glucagon and growth hormone was markedly elevated immediately after operation and during the first 2 postoperative days. The secretion of insulin was not also suppressed by operation. On the other hand, the plasma concentration of glucagon and growth hormone during postoperative period showed higher level in patients with lower caloric intake (under than 50 Cal/kg/day) than in those with higher caloric intake (over than 50 Cal/kg/day). Plasma insulin correlated with neither blood ketone body nor plasma free fatty acid during pre and postoperative period. In patients with lower caloric intake, however, the correlation between blood ketone body and glucagon as well as growth hormone, and the correlation between free fatty acid and glucagon as well as growth hormone were statistically significant in the postoperative period. These results suggest that accelerated hepatic fatty acid oxidation and hyperketogenesis would be influenced by hormones such as glucagon and growth hormone in those who have inadequate caloric intake after operation.
For the purpose of making clear the nervous mechanism in the aganglionic bowel segment of Hirschsprung's disease, electrophysiological and pharmacological studies were carried out on the muscle strips of the aganglionic and normal bowel segments of mouse and human. The aganglionic and normal bowel of mouse were obtained from piebald mouse and its normal sibling. Both the aeanglionic and normal bowel of human were obtained from the patients of Hirschsprung's disease at the corrective surgery. The junction potentials and tension developments in muscle evoked by field stimulation were recorded and analyzed by autonomic blockers. For recording the membrane potential and tension in muscle, the double sucrose gap method was used. In the normal segment, both excitatory and inhibitoay junction potential (e.j.p. and i.j.p.) evoked by field stimulation were recorded. After application of atropine or tetrodoxin, e.j.p.s disappeared. I.j.p.s were resistant to phentolamine and propranolol, but disappeared after application of tetrodotoxin. However, in the aganglionic segment, neither junction potentials nor tention developments were recorded at all. It was concluded from the present study that the aganglionic bowel segment is in a denervated condition without any nervous control.
The influence of anesthetics on gastroesophageal intraluminal pressure was studied using twenty one mongrel dogs. Eleven dogs were anesthetized with barbiturate (Barbital group) and ten dogs with ketamine (Ketamine group). The lower esophageal sphincter (LES) pressure with pull-through method and simultaneous gastroesophageal intraluminal pressure were measured. The results are as follows; 1) LES pressure was lower in Barbital group than in Ketamine group. 2) In measurement of simultaneous gastroesophageal intraluminal pressure, esophageal peristalsis was not induced by water instillation into pharynx, balloon distension or electrical stimulation of the upper esophagus in Barbital group. On the other hand, esophageal peristalsis and LES relaxation were induced and clearly identified. 3) In manometric study, anesthetic agent such as barbiturate which inhibit bowel motility, should be avoided and experimental condition must be standardized.
Percutaneous transhepatic nonoperative dilatation of the biliary stricture was accomplished in a 17 year-old female. She undewent a choledochoduodenostomy at the age of 2 years. At age 16 years, a hepaticoduodenostomy with a jejunal interposition was carried out resecting the common duct. She developed fever, jaundice, disorders in liver function and leukocytosis since 3 months after the second operation. Percutaneous transhepatic cholangiography was carried out at 1 year and 3 months after the operation. There was a severe stomal stricture. Nonoperative dilatation using a Gruntzig balloon catheter was successfully performed to dilate the stoma to 5 mm in diameter. Subsequent clinical course and result of laboratory tests have been satisfactory for 8 months after dilatation.
During the 12 years period from 1969 to 1980, 46 lymphangiomas were operated on in 16 infants and 30 children. The relationship between the postoperative complications and pathological characteristics was studied. Of these 46 cases, 16 were located in the cranio-cervical portion, 9 in the trunchal, and 10 in the abdominal cavity. Sixteen tumors had been detected prior to 1 month of the patient age. Twenty one cases were operated on prior to 6 years of age. 40 extirpations and 6 extirpationts with intestinal resection were done. Postoperative complications included 3 recurrences, 6 neurological problems, and 4 long-time lymphorroe. Pathological findings were classified into three types; cavernous 7, cystic 29, and others Remarkable infiltration into the normal tissue was seen in 33 cases, and inflammation with lymphocyte concentration in 8 cases. It should be noted that lymphangiomas which developed postoperative complications commonly showed the significant infiltrative pathological findings.
We have performed plastic operations for 10 patients with adrenogenital syndrome from 1979 to 1981. For the hypertrophied clitoris, clitorectomy was performed in 4 cases, embedding of the clitoris in 1 and clitroplasty in 5. Vaginoplasty was performed by the midline incision in 4 and by reversed U-shaped incision in 2. Changes of each of these operative technics are discussed with presentations of cases of own experience with review of pertinent literatures.
The results of surgical management of LBWN was reviewed. In 261 cases of surgical neonates who have been operated on at our institution during the past 20 years, 65 (25%) were LBWN with birth weight below 2,500 gm. In these 65 patients, the operative mortality was 55% (36/65), whereas 24% in mature neonates. The mortality was as low in Appropriate-For-Date neonates with birth weight more than 2,0)00gm as that in mature neonates. However, in preterm neonates under 33 weeks of gestational age and Small-For-Date neonates below 2,000gm of birth weight, the mortality was still high. One of the factors influencing the mortality is genarally considered an association of cardiac anomalies, but only 5 cases (28%) of LBW neonates died of cardiac origin in this series.
The record of 87 patients with neuroblastoma seen at our department between 1963 and 1982 were reviewed to study some of the features of patients with Stage IV-S neuroblastoma. Eight patients fitted the criteria of small or undetected primary tumor and distant diseases without evidence of bone metastases. Six patients had hepatic disease, 3 had skin lesions, and only 1 patient had disease in marrow. Five of the 8 patients survived, and 2 of 3 patients who died had bone metastases finally. These metastases were not detected in preoperative routine exami-nations. Postoperative chemotherapy and irradiation would be, therefore, necessary in the patients with Stage IV-S neuroblastom.
Permanent pacemaker therapy in children with complete heart block is necessary occasionally. Five patients ranging in age from 49 days to 12 years were treated with an implanted pacemaker. Indications for implantation were congestive heart failure, syncopal attacks, cardio-gegalia, brady-arrhythmia and persisting postsurgicsal heart block. There have been 15 pulse generator replacements. Problems unique to pacemaker implantation in children are ralated to the patient's size, the relative bulkiness of pulse generators, the lack of subcutaneous tissue and the child's growth and long life expectancy. Our experience proved that the placement of myocardial electrode in right ventricle and insertion of generator under the upper abdominal rectus muscle extraperioneally had been satisfactory in infants and younge children.
Ten cases of sacrococcygeal teratomas were treated at the First Department of Surgery, Osaka University Hospital from April 1971 to June 1982. All of the seven cases diagnosed under 6 months of age were of benign type with external extension, whereas 2 cases over 1 year of age were of malignant type with presacral extension. One case of 7 month-old-boy of presacral type was diagnosed initially as benign tumor, but tumor was recurred 1 year 10 months later. Alphafetoprotein must be followed over 2 years, therefore, in cases with benign tumor over 6 months of age or presacral tumor. Three of the 4 neonates with huge tumor died. Concerning about therapy for malignant sacrococcygeal teratomas, good response was obtained by VCB regi-men (vinblastine, cis-platinum and bleomycine).
An eleven-year old boy was admitted to our hospital with jaundice, splenomegaly and frequent episodes of epigastralgia. Anemia and jaundice were mild. Spherocytosis and anisocytosis in blood smear were found. Osmotic fragility of RBC was increased. Cholecystography and ultrasonography showed three stones in the gallbladder. He was diagnosed as congenital spherocytosis with cholelithiasis, but no family history was found with this disease. After splenectomy and cholecystectomy, the course of the patient was uneventful.
A 7 year-old girl presented with an abdominal mass in the epigastrium associated with abdominal pain, nausea, vomiting and fever. Laboratory findings showed slight anemia and liver dysfunction, but serum alpha-fetorotein and total bilirubin levels were within the normal range. Suddenly she had developed shock when the tumor ruptured into the peritoneal cavity. After blood transfusion she underwent a left hepatic lobectomy with dissection of the lymphnodes. The tumor was composed predominantly of necrotic tissue, blood and gelatinous matter, and was pseudocapsulated by fibrous connective tissues. It was histologically diagnosed as undifferentiated (Embryonal) Sarcoma. The post operative course had been satisfactory until three months later, when distension of the abdomen appeared. She died of cachexia 6 months after the onset of symptoms. Autopsy showed recurrence (probably implantation) of the tumor associated with hemorrhagic ascitet (about 3,200ml) but there was no metastatic lesions. Thirty-one cases reported by Stocker and Ishak, and nine cases reported in the Japanese literature were compared in this report.
Recently abdominal tumor in infancy and childhood is relatively easily diagnosed by Echography and CT-scanner, However, preoperative diagnosis of mesenteric cyst is occasionaly difficult because its sympton are variable. We have treated a case of mesenteric cyst associated with intramural hematoma of the jejunum of which initial diagnosis before operation was a miscellaneous acute abdomen. The patient was a three years old boy who was admitted with severe abdominal pain and bilious vomiting, but without palpable abdominal mass. The mesenteric cyst was localized in the mesenterium of the jejunum and adhered with the urinary bladder. Resulting of histological investigation, it was caverous lymphangioma.
Case 1: A 9-year-old boy fell off his bicycle and hit his abdomen against the handlebar. He complained of abdominal pain, which subsided within a few days. After an intermission of 3 months, abdominal distension was observed and pancreatic pseudocyst was diagnosed for the first time by ultrasonography. External drainage was performed successfully. Case 2: A 5-year-old boy was transferred from the other hospital 2 days after blunt abdominal trauma. He also fell off his bicycle. Serum amylase was elevated and traumatic pancreatic pseudocyst was diagnosed by ultrasonography. The patient was treated conservatively at first. His clinical course was satisfactory until 4 weeks after admissiom, when epigastralgia and abdominal distension recurred. Cystogastrostomy was carried out in emergency. His postoperative course was uneventful. Traumatic pancreatic pseudocyst is uncommon in children. Both of 2 cases presented here was correctly diagnosed by ultrasonography. The authors believe that the ultrasonography is the most reliable and non-invasive method for diagnosis of traumatic pancreatic pseudocyst. There still remain many difficulties for the management of pancreatic pseudocyst and also traumatic pancreatitis in children. Although it might be important to allow the time for the capsule of the pseudocyst to mature, the proper timing of surgery should not be missed.