The size of the external diameter of the internal inguinal ring was measured directly during surgery in 366 children with inguinal hernia in order to compare the difference of the diamiter sizes among different groups by sex, age, incarceration, and laterality. All patients were under the age of 15. Each average size was analyzed using unpaired Student's t-test. 1. A significant difference in the mean sizes of the diameter was observed between 33 male (8.8±3.3mm) and 10 female (5.6±2.2mm) infants under the age of 6 months. 2. A significant difference in the mean sizes of the diameter was also observed between 40 male infants with incarcerated hernia (9.4±4.6mm) and 183 without incarcerated hernia (7.4±3.4mm). 3. The size of the diameter of contralateral recurrent hernia was smaller than that on the previous side in female patients. The contralateral recurrence rate was 5 percent for both males and females.

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Thirty-five neurologically impaired children with gastroesophageal reflux (GER) underwent Nissen's fundoplication from October 1988 to January 1996. Nine of them died from causes other than GER and 2 patients were missed. Recurrence of GER was observed only in 2 patients (6.0%). The postoperative status of 24 patients was reviewed in light of quality of life (QOL) using a newly designed scoring system to analyze daily-life problems : vomiting, respiratory infections, feeding method, and weight gain as well as parents' degree of stress. Twenty-one patients were released from long-term hospital stay and went home after the operation. The authors conclude that QOL of neurologically impaired children with GER can be satisfactorily improved by aggressive antireflux operation.

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Extracorporeal membrane oxygenation (ECMO) has been recognized to be very effective for neonatal acute respiratory failure. However, it was somewhat difficult in some cases to obtain sufficient blood volume if venous drainage was obtained from the right atrium alone. In 1994, we started to use cephalic venous drainage to augment blood volume to the ECMO circuit. This supplemental technique was very effective to increase ECMO flow and maintain stable ECMO practice. Twenty-four cases have already been managed with this mode of ECMO. Supplemental cephalic jugular venous drainage might well contribute not only to resolve insufficient ECMO flow but also to decrease the incidence of intracranial hemorrhage.

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Although recurrence of hernia in children is less common than in adults, it still remains a clinical problem. The authors analyzed 17 cases of recurrent inguinal hernias in children treated between 1975 and 1996. Included in the cases were 13 boys and 4 girls. Recurrences were on the right in 8 cases and on the left in 9 cases. Although all 17 patients initially had indirect inguinal hernias, 14 recurrent cases showed indirect hernias while only 3 cases were direct hernias. In comparison of the recurrent cases between indirect and direct hernias, there was no significant difference in the ages at when the parents became aware of the initial hernias. There was also no significant difference either in the age at when the initial operation was performed or in the age at when the repair of recurrent hernia was conducted. There was, however, a significant difference in the duration between the first operation and recognition of the recurrence of hernia (p<0.01). The difference was also significant in the age at when the second hernia became apparent (p<0.05). The recurrent direct hernias took a longer duration to recur than the recurrent indirect hernias. Moreover, the age of second hernia recognition was older in the cases of recurrent direct hernias than that of the cases of indirect hernias. During the same period, there were 2, 966 cases of inguinal herniorrhaphy. The ratio of recurrent hernias was 0.573%, but 6 of the 17 recurrent cases were initially treated at other hospitals ; therefore, only 0.373% was the recurrent rate of in-house cases.

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We histologically and immunohistochemically examined porta hepatis from four patients with correctable or uncorrectable biliary atresia. In the correctable cases, acid mucin was prominent and CA 19-9 was diffusely observed in the cytoplasm of bile ducts at the porta hepatis. Collagen type IV (C IV), laminin (LN), and fibronectin (FN) were observed in the basement membrane of the bile ducts, while tenascin (TN) was negative. On the contrary, in the uncorrectable cases, neutral mucin was predominant and CA 19-9 was located weakly along the apical border of the bile ducts. All four of the extracellular matrix proteins were positive. Sialyl SSEA-1 (SLX) was absolutely negative in all four cases. These pathological findings suggest that there are biological heterogeneities in the bile ducts at the porta hepatis in patients with any type of biliary atresia. In addition, the genesis of biliary atresia was suggested to occur after 12 gestational weeks by the results of both CA 19-9 and SLX immunocytochemistry in our four cases.

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We analyzed feeding regimens after open surgical pyloromyotomy for hypertrophic pyloric stenosis (HPS). A total of 114 infants diagnosed with HPS were divided into three groups according to postoperative feeding regimens. The three regimens used in the study were as follows : Full feeding was accomplished in 2 days after the operation ; group A, n=43 ; in 3 days ; group B, n=37 ; and in 4 days ; group C, n=34. We studied the effect of feeding regimens on the postoperative vomiting and weight gain in all groups. We also examined gastric emptying before and after the operation. The results were as follows. (1) Mean vomiting episodes that occurred 3-4 days after the operation were 1.5/day in group A, 1.1/day in group B and 0.9/day in group C. Mean vomiting episodes that occurred 5-7 days after the operation were 0.7/day in group A, 0.9/day in group B and 0.9/day in group C. The difference among the groups was insignificant. (2) Mean periods to regain preoperative body weight were 3.7 days in group A, 4.1 days in group B and 5.9 days in group C. Group A and group B revealed significantly longer periods than that of group C (p<0.05). (3) Patients' demographies were not different among the groups except for the birth weight. (4) The relation between the postoperative weight gain and the feeding regimen was statistically significant in a multivariate analysis. (5) The gastric emptying taken at the preoperative period was impaired (5.4 ml/h), and that at 12 h after the operation had not improved (9.3 ml/h). At 24 h after the operation, it had improved (17.6 ml/h). At 48 h after the operation, it was almost the same as 24 h after (19.3 ml/h). These results indicate that postoperative feeding can start at 12-24 h after the operation, and be fully accomplished at 24-48 h after the operation.

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Between 1985 and 1996, 143 boys with nonpalpable testis underwent abdomino-inguinal explorations. No overt testis was found in 101 boys. Of them, 97 had spermatic vessels, vas deferens and/or nubbin and the diagnosis of vanishing testis was made, but 4 had none of these characteristics. The affected side of vanishing testis was left 71 (73%), right 24 (25%) and bilateral 2 (2%). All of the nubbins were located between the inguinal canal and scrotum. This evidence suggested that the vascular accident, a possible cause of vanishing testis, took place after 7 months of gestational age. While most of the spermatic vessels and vas deferens terminated in or below the inguinal canal, only 9 of them ended blindly above the internal inguinal ring. There were 3 rare cases in which the vessels and vas terminated above the internal ring, but the nubbin was also found near the scrotum and a fibrous, string-like structure was present in the inguinal canal connecting them. Histological studies of the removed nubbins revealed only fibrovascular tissue with occasional calcification and hemosiderin deposits in most of them, but viable germ cells were seen in 6 (7%). This finding warrants the removal of all nubbins to prevent potential malignancy.

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Ninety-eight infants with biliary atresia were operated at a children's hospital by a single pediatric surgeon during the period from 1970 to 1991. Among them, six atresias were classified as type I and type II ; therefore, Kasai's operation (hepaticoporto-enterostomy) was performed on the remaining 92 infants. Overall survival was obtained for 53 of the 98 patients (54.1%). Forty-three of the 92 patients with type III biliary atresia are alive (51.1%) as of the last follow-up (December 1997). Improvements in the results of treatment over the years were remarkable as new surgical techniques and medical treatments were established. Before 1981, there were only 15 survivors among 53 patients (28%) ; however, 32 of the 39 patients (82%) who were treated after 1982 survived. Five patients in this group underwent living-related liver transplantation, with four successful cases. Among the remaining 47 patients, three are indicated for liver transplantation at this moment and 6 may be indicated in the near future. It is concluded that Kasai's operation is effective in 70% of biliary atresia patients and 30% require liver transplantation for complete cure.

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Arterio-venous extracorporeal membrane oxygenation (A-V ECMO) was established in goat fetuses via the umbilical vessels following incubation in a warm bath. The effect of A-V ECMO on fetal lung growth and maturation was evaluated. Eight goat fetuses of 120-130 days' gestation (trem, 150 days) were subjected to this immersion ECMO system. Tracheal ligation was performed on four fetuses (tracheal occlusion group). Tracheal ligation was not performed on the other four fetuses (trachea-open group). Four littermate fetuses with similar body weights were harvested and examined as baseline data before ECMO was performed (non-ECMO group). The mean duration of A-V ECMO was 107±41 h in the trachea-open group, and 139±67 h in the tracheal occlusion group. Mean fetal weight after ECMO was significantly higher than at the time of initiation of ECMO in the tracheal occlusion group. Phosphatidylcholine and disaturated phosphatidyl-choline in the lung tissue after ECMO were significantly higher in the tracheal occlusion group than in the non-ECMO group. Wet lung weight after ECMO was significantly higher in the tracheal occlusion group than in the non-ECMO group. Dry lung weight and dry lung weight/body weight were significantly higher in the tracheal occlusin group than in the non-ECMO group. Electron microscopy demonstrated a higher increase in type II cells/alveolar epithelial cells in the tracheal occlusion and trachea-open groups than in the non-ECMO group. Plasma cortisol levels were significantly higher in the tracheal occlusion group than in the non-ECMO group. T3 levels were significantly higher in the tracheal occlusion group as compared with the trachea-open group, and significantly higher in the trachea-open group as compared with the non-ECMO group. Fetal breathing movement appeared in two fetuses in the trachea-open group and two fetuses in the tracheal occlusion group. In this immersion fetal A-V ECMO system, tracheal occlusion affected the production of surfactant, and caused an increase in lung weight and type II alveolar epithelial cells.

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The aim of this study is to investigate the deterioration of liver function in jaundice-free long-term survivors after portoenterostomy. The subjects are 17 patients with biliary atresia who have survived for more than 10 years after portoenterostomy and have received continuous follow-up examinations at our institution. The serum levels of total bilirubin and liver enzymes (GOT, GPT and γ-GTP) at 5 and 10 years of age, and current data were analyzed. Total bilirubin was less than 1.0 mg/dl at 5 and 10 years of age in all patients but one. Two patients who underwent liver transplantation after 10 years of age and 2 transplant candidates showed more than 100 IU/l of GOT, GPT or γ-GTP at 5 years of age. No one who had more than 100 IU/l of either enzymes at 5 or 10 years of age recovered to less than 40 IU/l of all enzymes at the time of this writing. On the other hand, 4 patients who had less than 40 IU/l of all enzymes at 5 year of age, and 4 of 7 patients who had less than 100 IU/l of all enzymes at 5 years of age currently show less than 40 IU/l of all enzymes. These results suggest that liver function gradually deteriorates in the patients who had more than 100 IU/l of GOT, GPT or γ-GTP at 5 years of age, and they will be possible candidates for liver transplantation in the future.

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We report 3 cases of a rare association of uterus didelphys, a unilateral hemivaginal obstruciton and ipsilateral renal agenesis. Case 1 : A newborn girl was suspected of having hydrometrocolpos based on antenatal ultrasonography (USG) findings and she presented with a vaginal cyst after birth. USG demonstrated a double uterus and vagina associated with hemivaginal obstruction and ipsilateral renal agenesis. An incision was made on the vaginal cyst by a vaginal approach immediately after birth. Case 2 : A 12-day-old girl showed a cystic pelvic mass based on antenatal USG findings. It was diagnosed to be an ovarian cyst after birth. The mass was later confirmed to be hydrometrocolpos at the time of operation. A vaginal septectomy was carried out at 6 months of age. Case 3 : A 11-year-old girl was admitted to our hospital due to lower abdominal pain. USG, CT, and MRI showed a hematometrocolposalpinx due to a vaginal obstruction. An excision of the vaginal septum was done through a vaginal approach. The postoperative courses of all cases were uneventful with no recurrences. The relevant Japanese literature was reviewed regarding the symptoms, diagnosis, and associated anomalies in such cases.

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The incidence of injury to the pancreas following either blunt or penetrating abdominal trauma in children is relatively uncommon. We report a case of traumatic transection of the pancreatic duct, and the clinical features of this rare condition are reviewed through 14 reported cases in literature in Japan. A 5-year-old girl who sustained a blunt abdominal injury was transferred to the Department of Emergency and Critical Care Medicine of Kansai Medical University. Transection of the body of the pancreas was clearly demonstrated by enhanced computer tomography. At laparotomy, isolated transection of pancreatic parenchyma with division of the main duct was found adjacent to the right side of the superior mesenteric vein. The proximal cut end of the pancreas was closed, and pancreatojejunostomy was performed in the Roux-en-Y fashion (Letton-Wilson's procedure). The clinical outcome was excellent, and pancreatic function has been well preserved for seven months postoperatively. Distal pancreatectomy with or without splenectomy and drainage has been advocated as a standard surgical procedure for transection of the body of the pancreas. However, Letton-Wilson's procedure is an alternative surgical procedure to preserve distal pancreas, for those whose general condition is stable and injury at the surface of the distal pancreas is minimal and pancreatojejunostomy can be presumed to be safely performed.

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An 8-year-old boy was admitted to our hospital because of fever and icterus. Laboratory data demonstrated obstructive jaundice, liver dysfunction, and inflammatory reactions. Ultrasonography and percutaneous transhepatic cholangiography revealed calculus in the cholecystic duct compressing and obstructing the common hepatic duct. The diagnosis of cholecystolithiasis complicated by Mirizzi syndrome (confluence stone type) was made. At laparotomy, severe adhesion due to an inflammatory process of the hepaticoduodenal ligament was seen, and cholecystectomy followed by hepaticojejunostomy was performed. The histopathological diagnosis was chronic cholecystitis. Postoperative course was uneventful. Now, he is doing well 6 years after the operation.

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A case of a 13-year-old female with ovarian abscess after appendectomy for perforated appendicitis is reported. The patient underwent intraabdominal drainage followed by appendectomy for perforated appendicitis. She later became febrile and complained of lower abdominal pain again, and was readmitted. An echogram and computer tomography revealed an intrapelvic multilocular cystic mass, which was suggestive of either ovarian cyst or intrapelvic abscess. Antibiotics did not improve the condition. The mass became larger, and an intrapelvic abscess was suspected. She underwent laparotomy at 76 days after the appendectomy. At surgery, the right ovary was found to be swollen with a maximal diameter of 7 cm, and pus was discharged from the ruptured ovary. Right salpingo-oophorectomy was performed, and she recovered very well and was asymptomatic at discharge. Histopathology revealed a loss of normal structure of the ovary and substitution by the inflammatory tissue. Ovarian abscess is an unusual gynecologic infection, whereas tubo-ovarian abscess is relatively common. Appendicitis could be a cause of ovarian abscess. In such cases, bacteria is thought to enter the ovary directly through the capsule. Although a chance of ovarian abscess after appendicitis seems to be very slim, the presence of this rare condition should be considered when pelvic mass is observed after appendectomy.

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We report a case of delayed stricture of the small bowel after blunt trauma in an 11-year-old girl and review reported cases in Japan. The patient was injured when the handle of her bicycle hit her lower abdomen. Nine days after the accident, she developed intermittent abdominal pain and vomiting and was hospitalized elsewhere. She underwent an appendectomy because there was a risk of acute appendicitis, however, no inflammatory changes were seen in the appendix ; although there were a few portions of spastic small intestine without organic changes. She was referred to our hospital because of persistent symptoms of partial bowel obstruction. A small bowel contrast study demonstrated a stenosis in the middle portion of the small intestine with proximal distention. A second laparotomy was performed one month after the accident and a segment of stenotic small intestine 270 cm proximal to the ileocecal valve was resected. Microscopic examination of the stenotic bowel revealed ulceration, submucosal inflammation, and fibrosis. Delayed small bowel stricture after a blunt trauma is extremely rare in children. There have only been 44 cases including this case reported in Japan, and of these only 6 were pediatric cases. Post-traumatic stricture of the small bowel should be suspected in patients who develop signs and symptoms following blunt abdominal trauma. Surgical treatment is indicated because the lesion involves organic change with subsequent fibrosis.

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