Recent development of perinatal care achieved a significant improvement both in the results of neonatal intensive care and in the regional network. A good example showd that a majority of extremely low birthweight infants were given birth after in-utero transfer to the perinatal center. Japanese government endorced a new scheme on the regional perinatal organization starting 1996. The content of neonatal intensive care is not straightforward. It includes maternal transfer, fetal maturation, fetal diagnosis, neonatal resuscitation, management of acute illness by the use of modern intensive care techniques, maintenance of good intensive care environment protection of brain injury, the care of recovering infants for growth and development, care for the family, and finally to offer a good follow-up system. The neonatal surgery made a significant improve-ment, too. The target at present may be firstly to achieve comprehenisve care environment as mentioned above both in the hospital and in the region. Secondly to explore the possibility of improving outcome by the use of fetal diagnosis. The final figure may be the establishment of a good sized neonatal surgical unit in the region, which is sufficient to offer regional surgical care, training for postgraduate, and research.

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Operation for pediatric patients is so important that it occupies about twenty percents in operative cases of plastic and reconstructive surgery. Recent progress in the field of plastic and reconstructive surgery is so remarkable as other fields of surgery. They were delivered by many kinds of skin flap transfer and composite tissue transfer which had been made possible as the results of elucidation for vascular supply to various tissue accompanying with develop-ment of microsurgery. Present situation of pediatric surgery in plastic and reconstructive surgery is described in this report about cleft lip and palate, craniofacial surgery, microsurgery, congenital anomaly of the hand, skin and muscle flap and allogeneic skin and soft tissue transfer.

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New advances on the following specific subjects in Pediatric Neurosurgery are summerized ; hydro-cephalus, lipomyclotneningocele, syringomyclla, craniopharyngiomas, germ cell tumors, medullo-blastomas, optic gliomas. pituitary adenomas, arteriovenous malformations and spinal cord injury.

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Recent clinical investigations suggest that most neuroblastomas found in infants less than one year old, including those detected at 6 months by VMA/HVA mass screening show extremely benign clinical behavior. In this study, focusing upon the differen-tiation/maturation process and apoptosis, we analyzed the hislological features of neuroblastoma in patients examined between 1985 and 1994. Patients were divided into two groups, and 72 patients of less than one year old (7.9±2,5 mo), and 26 patients of over one year old (4.3±3.3 yr) were examined. There were no tumor deaths among less than one year old patients, compared with 16 deaths among over one year old patients. We used four antibodies for immunohistochemical studies. The in situ end-labelling (ISEL) method was used for demonstration of apoptosis. The rates of expression of S-100 protein, neural cell adhesion molecule ( NCAM) and microlubule-associated protein-2 (MAP-2) were significantly high in less than one year old patients. There was no significant difference in the expression of vasoactive intestinal polypeptide (VIP) and in that of apoptosis between less than one year old patients and over one year old patients. Among over one year old patients, whose tumor showed no expression of S-100 and MAP-2 had an poor prognosis. Among the two antigens examined, lack of MAP-2 expression was indicative of a very poor prognosis. It was suggested that tumor differentiation/maturation was progressive in less than one year old patients, and that MAP-2 expression was the most striking factor correlated with patient prognosis.

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Various types of abnormal basement membranes appear in chronic liver diseases. Especially, the basement membrane beneath the sinusoidal endothelial cells, which indicates a transition to a closed circulation from an open one in the space of Disse in liver cirrhosis is well known as 'capillarizalion of sinusoid'. We observed basement membranes in the liver tissue of biliary atresia by transmission electron microscope. Sixteen patients had been jaundice free after hepatic-portoenterostorny (group I). Liver specimens were taken surgically at hepatic-portoenteroslomy and closure of enterostoma (age from eight months to three years). Four patients (age from one year to sixteen years) had jaundice (group II). Three types of abnormal basement membranes were revealed. One was beneath the sinusoidal en do the rial cell. It was seen in only two patients of group I, whereas in three patients of group II. Especially in one patient who underwent liver transplantation, it was remarkably thick and seen broadly in cirrhotic lobules. The second type located on the surface of hepatocytes of limiting plate. This type was seen variably in group I, but in group II it appeared frequently in most of the cases. The third type was stratified membrane seen around the bile ductules. It was formed around not only the proliferated bile ductules, but also the nearly normal bile ductules in group L The authors concluded that capillarization of sinusoids scarcely occured in cases without jaundice in biliary atresia. and basement membranes on the limiting plate and stratified membranes around the bile ductules might indicate the existence of cytotoxic factors.

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DNA cleavage, a marker of apoptosis, has been used to study the regression of malignant tumors. To evaluate the relationship between clinical stage (or prognosis) and apoptosis. DNA fragmentation with 3'-end-labeling (or Nick's end labeling method) was investigated in formalin-fixed, paraffin-embedded tissue specimens from 23 neuroblastoma cases and 4 biopsy specimens of primary n euro blastemas (NBLs). Clinical stage of these NBLs is as followed ; stage I ; 4 cases, stage II ; 2 cases, stage III; 6 cases, stage IV ; 9 cases, and Stage IVs ; 2 cases. DNA fragmentation was positively expressed in ail 27 cases of NBLs. However, the ratio of positive cells did not change significantly in clinically early stage group from that in advanced stage group. The ratio of positive cells in each stage was as followed ; stage I; 0.07, stage II; 0.03, sulage III ; 0.04, stage IV ; 0.10. and stage IVs ; 0.11. Before and after chemotherapy, the ratio of positive tumor cells in same tumor did not change. Apoptotic change in tumor was considered not to be a useful marker for a spontaneous regression in clinical NBLs.

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A case of biliary atresia (BA) associated with omphalocele and meconium peritonitis was reported. During an operation for omphalocele and meconium peritonitis, we observed a normal gall bladder. After the operation, jaundice developped and persisted. On day 57, intraoperative Hiolangiogram revealed BA (III-al-v), and hepatic porto-enterostomy was performed. After the Kasai procedure, janundice diminished. There are some reports of BA with some congenital diseases that need the laparotomy, Even if we observed the gall bladder during the previous operation, BA shoud be considered when jaundice continues. It cannot be denied the possibility that meconium peritonitis causes, BA, but it's not evident from thiscase.

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A 4-year-old boy was admitted to our Hospital with the complaints of anorexia and abdominal pain. A firm and rounded mass was palpated in the right upper quadrant. The CT scan revealed a large solid mass in the transverse colon. At surgery, a 7×8cm tumor of the transverse colon which extended into the mesoeolon was noticed and excised en bloc. Inflammatory pseudotumor was diagnosed on microscopic examination. Thirteen cases of inflammatory pseudotumor of bowel and bowel-mesentery in the literature were reviewed. Among them 12 cases were observed in children with no distinction of sex.

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The natural history'of the histological findings of nesidioblastosis (NB) remains unclear. We examined histologically the resected pancreatic specimens from a girl with NB at the age of 2 months and 8 years, and evaluated whether NB has the potential for matruration with aging. A girl, diagnosed as Beckwith-Wiedemann Syndrome antenatally. showed hyperinsulinemic hypoglycemia immediately after birth. Laparotomy, performed at the age of 2 months, revealed a 3-cm-sized mass located in the body of the pancreas. Distal pancreatectorny was performed, but because of operative difficulties, the proximal half of the mass was left at the edge of pancreas body. Hislological studies, however, revealed that NB was diffusely located throughout the resected pancreas. The diagnosis was diffuse nesldioblastosis with localized nesidioblastoma. While hyperinsulinemic hypogiycemia had gradually attenuated with aging. she presented hypoglycemic attacks occasionally for 7 years, and continuous subcutaneous administration of sandostatin was performed for one year. To avoid the adverse effects of somatostatin, subtotal pancre- atectomy was performed at the age of 8 years. Hisle-logical examinations disclosed that the acini of the pancreas were normalizing compared with the previously resected materials, but they were still mixed with endocrine cells, moreover, some islets of Langerhans had formed in part of the resected pancreas. These histologicai changes point to the phenomenon of maturation of nesidioblastosis with aging.

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We report a rare case of pyosalpinx in childhood. At the age of two months she had the right colostomy under the diagnosis of Hirschsprung's disease. At the age of eleven months she had the radical operation with the modified Duhamel-Ikeda procedure and then underwent re-laparotomy due to the leakage and pan peritonitis at the 7 days after the radical operation. At the age of 1 year and 3 months colostomy was closed. At the age of three years and five years, she had adhesive ileus which improved with conservative treatments. At the age of eleven years she complained of the ieft lower abdomina! pain and a high-fever was found. At the laparotomy she was found to have the left pyosalpinx and the right hydrosalpinx. We performed left salpingectomy and right salpingostomy. Peritonitis after the radical operation for Hirschsprung's disease and adhesive ileus might cause the obstruction of the bilateral salpinx.

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A tecnique for the treatment of subglottic stenosis is reported. A composite hyoid bone with sternohyoid muscle graft is used to replace the stenotic region of the airway. A midline incision is made through the anterior wall of the lower half of the thyroid, cricoid and first tracheal ring, and the composite hyoid-sternohyoid graft is interposed. A 4-year-old boy with acquired subglottic stenosis was treated. Postopcratively a Silastic T-tube was used because of re-stenosis with some firanulation tissues. Ten months after operation, bronchoscopy revealed wide trachcal lumen without a granulation tissue and the tube was removed. The following are advantages of this operative tecniquc ; 1) The blood supply for the graft aids in diminution of infection. 2) The attached muscle helps the stabilization and fixation of the graft. 3 ) The maintenance of the composite hyoid bone with sternohyoid muscle is no more technically difficult than free hyoid bone graft. 4 ) This technique requires no other separate operative site. 5) This technique avoids the disturbance of normal laryngeal growth.

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Neuroblastoma staging system of The Japanese Society of Pediatric Surgeons (JSPS) was compared to the International Neuroblastoma Staging System (INSS) to clarify its characteristics. Taking into accounl the resectabilily of the primary tumor and having different criteria for lymph node involvement, the INSS substantially differs from the JSPS staging system. To make the results of clinical trials and biological studies that are conducted in our country internationally acceptable, we propose that neuroblastoma patients should be registered according to the INSS in addition to the staging sytem of the ISPS.

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