Purpose : The aim of our study was to investigate the significance of preoperative stabilization of patients with congenital diaphragmatic hernia (CDH), the timing of surgery, and the effectiveness of our protocol. Methods : A retrospective analysis of an emergency surgical repair group (n=23) and a delayed surgical repair group (n=29) was performed. All 52 cases of CDH were diagnosed within the first 24 hours of life and began to be treated soon after birth. Results : Survival rates for the two groups were 82.6% (emergency group) and 72.3% (delayed group) respectively, and this difference was not statistically significant. Patients whose best AaDO_2 could be maintained at ≦250 torr by the time of surgery all survived. There was a negative correlation between best AaDO_2 and LW/BW ratio. Conclusions : The average survival rate for surgery performed according to our protocol was 90.9%. [1. Our protocol involves improving persistent pulmonary hypertension of the newborn (PPHN), 2. Elimination of flip flop. 3. Stabilization of cardiac function. 4. Maintenance of AaDO_2≦250 torr.] Patients who underwent surgical repair according to our protocol were easy to manage. The improved survival rate of the delayed surgical repair group was probably due to planned delivery to best facilitate treatment. We believe that untreatable cases with severe pulmonary hypoplasia can be selected out by persisting with our protocol for stabilization for at least 24 hours. If the patient can not be stabilized, successful outcome is unlikely.

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Purpose : The authors reviewed the results of peritoneal cultures in children with perforated appendicitis (PA) to clarify the bacteriology and to elucidate the appropriate choice of antibiotics. Materials and Methods : A retrospective chart review of 159 PA patients between 1986 and 2000 was performed. The results of intraoperative peritoneal cultures and the activity of antibiotics against the isolated bacteria were examined. Data were compared between a first period (1986-1992) and a second period (1993-2000) to determine any differences depending on time-course. Results : An average of 1.81+0.82 pieces of pathogenic organisms per specimen were isolated from 155 of 159 patients (97.4%). The most frequently isolated pathogen was Escherichia coli (E. coli) (38.2%), followed by Streptococcus sp. (14.6%), Pseudomonous aeruginosa (12.5%), and Bacteroides sp. (10.8%). When the first and second periods were compared, there was no marked difference in the incidence of bacterial cultures except for those of E. coli and Streptococcus sp. The activity of several antibiotics against the isolated bacteria was not dramatically different between the two periods. A combination of cefmetazole (CMZ) and amikacin (AMK) showed equal or even better activity. Conclusions : The bacteriology of peritoneal cultures and the sensitivity of the pathogens to antibiotics did not significantly change over time in PA patients. Therefore, the choice of antibiotics for empirical therapy should not be changed, and the use of CMZ and AMK remains appropriate for the treatment of PA.

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Purpose : Based on the importance of the core curriculum (CC), we have re-examined and established the CC for surgery. We investigated objectives for CC and related problems. Subjects and Methods : We classified objectives for surgical education edited by the Association for Surgical Education as either knowledge or skill acquisition. Two nationwide surveys were conducted to select objectives for the CC of surgery. We calculated scores for each objective according to the necessity of acquiring particular knowledge or skill and statistically analyzed the data. Results : Clusters of objectives were classified into two groups as knowledge and skills. We considered a cluster of objectives with a high score as appropriate for inclusion in the CC. Eleven objectives (5.6%) were associated with knowledge about pediatric surgery and three (4.6%) were associated with related skills. Conclusions : The number of objectives for pediatric surgery is restricted in the CC for surgery.

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In this paper, we describe the case of a newborn baby with giant cystic meconium peritonitis (GCMP), who was successfully treated by peritoneal drainage on day one of age and by ileoileal anastomosis on day four. This patient was found to have a fetal abdominal cyst by prenatal ultrasonography at 32 weeks gestation. After birth, the baby deteriorated rapidly because of progressive respiratory failure. The baby underwent peritoneal drainage on the first day of age and radical surgery on the fourth day. The cystic wall was remarkably thickened and severe adhesions were found in the peritoneal cavity. However, the adhesions between the intestinal loops were not so severe, and ileoileostomy could be performed with ease. The postoperative course was uneventful. In GCMP babies, adequate understanding of anatomical orientation in the peritoneal cavity and preoperative stabilization facilitate radical surgery even in the newborn period.

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A case of Peutz-Jeghers syndrome with gynecomastia is presented, and the pertinent literature is reviewed. A seven-year-old boy was admitted because of gynecomastia. A diagnosis of Peutz-Jeghers syndrome had already been made when a polyp in his colon was removed at one year old. In his family history, only his mother has Peutz-Jeghers syndrome. At admission pigmentations in lips and oral mucosa were noted and bilateral gynecomastia was prominent. Bilateral subcutaneous mastectomies with minimum periareolar incision and biopsy from left testis were performed. The pathological diagnosis of testis was Sertoli cell tumor. One year later, he began to have frequent abdominal pain attacks. A UGI examination revealed multiple polyps in the small intestine. Using intraoperative fiberscope all polyps were removed with or without partial intestinal resection. Postoperative course was uneventful. Peutz-Jeghers syndrome associated with gynecomastia is a rare condition. Only 20 cases of this combination, including our case, have been reported and all of them had this pathological testicular condition : Sertoli cell tumor, which is suspected at producing gynecomastia. Sertoli cell tumor is treated as benign usually but its potential for malignancy is recognized. So follow up of testis as well as polyposis is important.

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Lumbar hernia is one of the rarest varieties of abdominal parietal hernias. It occurs through weak point of either the superior lumbar triangle or the inferior lumbar triangle. In this paper, a case of bilateral congenital lumbar hernia is reported. The patient was an 18-month-old female infant presenting with a bilateral bulge in the lumbar area. Contrast enema, computed tomography and magnetic resonance imaging were useful in the preoperative diagnosis of bilateral lumbar hernia showing defect of the parietal abdominal wall. An operation showed herniated retroperitoneal fatty tissue through the defects in the inferior lumbar triangle. The defects were closed directly as follows : The internal oblique muscle and spinal erectoty muscle were closed, then the external oblique muscle and latissimus dorsi muscle were brought together and sutured. The defect in our experience does not call for a prosthetic material. The patient showed an uneventful recovery. She showed no evidence of recurrence during a one-year follow-up period.

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We sometimes encounter intestinal prolapse from the stoma in infants. In infants, surgical repair should be avoided if possible. In this paper we report 2 cases of intestinal prolapse from the stoma in anorectal malformations for whom we could protect the intestinal prolapse from the stoma using a hand-made suppression. The suppression was made of polyethylene suction tubes or a net for handicraft. With this device we could control well these infants with intestinal prolapse until closure of the stoma. In such cases, therefore, we should alternatively chose such a conservative treatment, before resorting to surgical intervention.

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We report on a case with gastroschisis and multiple intestinal atresia in which intestinal output was administrated from oral-side jejunostomy to anal-side residual gut as a nutritional management technique. During the operation for intestinal atresia, a double-barrel type jejunostomy was constructed for the prophylaxis of anastomotic leakage. The residual intestinal length was 45 cm from the jejunostomy. TPN was initialed just after the operation. He started oral intake 2 weeks after operation and intestinal output from oral jejunostomy was administered to anal-side gut with ursocolic acid, dietary fiber, and stomach and intestinal medicine. He gained body weight rapidly, and his jejunostomy was closed 222 days after birth. At that time the residual intestine reached 70 cm in length. We conclude that enteral nutrition using jejunostomy is very effective for the development of intestine as well as patient's growth.

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On March 29, 2001, the "Ethical Guidelines for Human Genome and Genetic Sequencing Research" were established. They are intended to serve as "ethical guidelines for all human genome and genetic sequencing research practice, for the purpose of upholding respect for human dignity and rights and enforcing use of proper methods in the pursuit of human genome and genetic sequencing research, with the understanding and cooperation of the public". The Radiation Sensitivity Genetic Research Project has prepared a research protocol and informed consent document that follow these ethical guidelines. We have endeavored to protect the privacy of individual information, and have established a procedure for examination of research practices by an ethics committee. Here, we report our results, in order to assist the future development of basic research or group studies by members of the Japanese Society of Pediatric Surgeons.

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