Purpose A transportation system for newborns has contributed to improvement in the regional medical care for neonates in all three areas (eastern, central and western areas) of Shizuoka Prefecture In 1998, a general perinatal care center for high-risk pregnancy and newborn children was established in the western area, however there are still no effective, efficient perinatal care systems in the eastern and central areas. The incidence of surgical neonates have been investigated since then, and problems relating to neonatal surgery were examined in Shizuoka Prefecture. Methods A questionnaire was used to survey the number of surgical neonates, operations, and prenatal diagnoses in Shizuoka Prefecture from 1999 to 2001 Surgical neonatal rates, fetus diagnosis rates, and stillbirth rates in all three areas of Shizuoka Prefecture were calculated, and the problems were examined based on these data. Results Although the numbers for births and population were almost the same during this 3-yearperiod, the number of surgical newborn cases increased. The annual incidence of newborn surgical admissions was 2 34 per 100,000 total population (215 in the eastern area, 196 in the central area, and 2 97 in the western area) and 248 per 10,000 live births (217, 212, and 31, respectively). The incidence of newborn operations was 191 per 100,000 total population (165 in the eastern area, 1 56 in the central area, and 2 5 in the western area) and 201 per 10,000 live births (161. 169, and 262, respectively). In the western area, the number of surgical newborn cases was approximately 15 times higher than that in the eastern and central areas. Moreover, the fetus diagnosis rate in the western area was higher as compared to the diagnosis rates in both the eastern and central areas. Conclusions Once a perinatal care system is established, the surgical babies, who are unable to receive the proper care, will be transported to pediatnc surgical facilities. To provide for safe and effective treatment of surgical babies before, during and after delivery, the immediate establishment of effective and efficient perinatal medical care systems is necessary in both the eastern and central areas of Shizuoka Prefecture.

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In order to clarify the current status of regionalization for surgical newborns, patients born in Aichi Prefecture from January to December 2000 were investigated using a questionnaire Two-hundred-and-twenty-two newborns were registered including 46 cases of imperforated anus, 22 cases of diaphragmatic hernia, 14 cases of esophageal atresia and so on. An antenatal diagnosis was made for 55 cases (241%). Of those, 6 cases were interrupted, 15 cases of diaphragmatic hernia were included, and 24 cases were followed by maternal transport The overall mortality was 10.4% Regionalization of neonatal surgery in this area has been completely established, and 92.4% of all cases were managed by pediatnc surgeons certified by the Japanese Society of Pediatnc Surgeons.

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We have organized a co-operative system for neonatal surgical care to facilitate regionalization in Osaka since September 1993 The activities included promoting prenatal diagnosis and transportation of patients to appropriate facilities according to the severity of the disease. A review of patients' data for six years from 1995 revealed increased prenatally diagnosed patients and an improvement in outcome. Regionalization of pediatric surgery, including neonatal surgery, may improve patient outcome and should be considered for other regions in Japan.

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Purpose A low birth rate may be the cause an decrease in the number of patients who require pediatric surgical care in several centers of pediatric surgery in recent years In order to evaluate regional differences between each prefecture in the Kyushu-Okinawa area, the relation between number of live birth infants and specialized pediatric surgeons was studied. Methods The number of live birth infants in the past 20 years, and the number of qualified specialized pediatric surgeons (QSPS, "Shidoi"), specialized pediatric surgeons (SPS; "Nmten") and qualified pediatric surgical centers (QPSC, "Nmteishisetsu") were estimated for each prefecture and compared with those for all of Japan, the USA, and the UK Results. The number of live birth infants decreased about 70% in the past 20 years. The rate of decrease in Okinawa was the lowest. The numbers for QSPS and QPSC in the Kyushu-Okinawa area were lower than those for the rest of Japan Especially, Nagasaki, Miyazaki, and Okinawa lacked QSPS as well as QPSC Miyazaki also lacked SPS Conclusions Since pediatric patients who require surgical treatment should be managed by specialized pediatric surgeons instead of general surgeons, the following ideas are proposed (1) In order to create SPS and QSPS, a "matching system" should be utilized (2) Re-distribution of QPSC should be considered by the government (3) The social insurance system should be revised.

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This report addresses the present state of the regionalization of pediatric surgery in Japan, with specific reference to one particular area, Kagoshima Prefecture in Southern Kyushu. The number of pediatric surgical cases was estimated to be about 1800 in the fiscal year of 1995 Of these cases, 515 underwent surgery in two institutions with full-time pediatric surgeons and about 100 cases underwent surgery in medical association hospitals with part-time pediatric surgeons. In Kagoshima Prefecture, there are only two facilities where neonatal surgery can be performed and almost all neonatal surgery is earned out in these facilities Pediatric surgeons generally operate on most of the infants and young children However, general surgeons perform surgery on school children and junior high school students Operative procedures by general surgeons are limited to inguinal hernorraphy or appendectomy. At the present time, in Kagoshima Prefecture, it is impossible and impractical to treat all pediatric patients in the pediatric surgical institutes. For regionalization to work, it is important to construct an effective system of cooperation between pediatric institutes and respective hospitals. The dissemination of knowledge gathered at these pediatric institutions to other hospitals and physicians is also of great importance.

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Purpose The Japanese Society of Pediatric Surgeons (JSPS) has endeavored to increase authorized pediatric surgeons and facilities for nationwide recognition of pediatric surgical subspecialty. However, there has been a lack of assessment of current markets for pediatric surgery or the outcome of pediatric surgeons' employment research. This paper recommends an appropriate allocation of qualified pediatric surgeons and facilities in Japan to meet the current market demand. Methods Based on the clinical performance in the pediatric surgical department of Saitama Municipal Hospital, the workload required for a pediatric surgeon to adequately meet the budget balance in the Japanese Health Insurance System was calculated. The rate of pediatric surgical patients among the pediatric population was calculated by dividing the whole pediatric population by the number of hospitalized pediatric surgical patients registered in annual reports of the Certifying Committee of the JSPS. According to the calculated data, the size of the workforce market for pediatric surgeons was estimated. Results An income of 91,558,000 yen/doctor/yr is required to adequately meet the hospital budget balance. A pediatric surgeon should have 220 hospitalized patients, conduct 164 operations and have 2,750 outpatients per year to earn this amount. Numbers of pediatric population were calculated at 484 per hospitalized patient and 626 per patient needed operation. The estimated pediatric surgical market to keep with the pediatric population was 188 pediatric surgeons and 50 facilities nationwide. The modest market for pediatric surgical manpower in each administrative division of Japan was also recommended based on pediatric populations in each district using a regionalization map. Conclusions The current supply of pediatric surgeons and facilities has exceeded the demand Leaders of the JSPS need to give serious consideration to workforce adjustment in order to maintain the highest quality of pediatric surgical care in the context of the current and future market. Construction of a novel common nationwide system is mandatory.

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The distribution and regionalization of the pediatric surgeons in Japan were analyzed, and some farsighted actions by the Japanese Society of Pediatric Surgeons (JSPS) were discussed Japan had a population of 126,925,843, a childhood (under 16 years of age) population of 19,910,849 and a total of 1,190,337 births in 2000 The professional education system for pediatric surgeons by the JSPS had 132 certified training institutions, 208 certified instructors for pediatric surgical training, and 412 pediatric surgical professionals in 2000 Target populations for each unit were, 150,840 children and 9.018 births for an institute, 95,725 children and 5,723 births for an instructor, and 48,327 children and 2,889 births for a professional respectively. Although, these numbers would be considered as appropriate for the training system, the tendency for a continuous decrease in the number of children over several decades will force the JSPS to introduce some regulations in the near future. The uneven distribution of institutes, instructors, and professions is a problem to be resolved presently. The areas not equipped with these facilities had a large number of children, and the target population of facilities differed about 10 times between the overcrowded and sparse density area of pediatric surgeons.

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Purpose The purpose of this clinical trial was to evaluate the usefulness of preoperative decompression and irrigation through a transanal tube in order to perform a one-stage pull-through procedure for Hirschsprung's disease (HD). Methods Over the past three years, 16 patients with HD diagnosed in the neonatal period were managed with preoperative decompression and irrigation through a transanal tube. The mean age and weight on admission was 64 days, and 30 kg, respectively. The extent of aganglionic segment varied as follows rectum in six patients, rectosigmoid in five patients, sigmoid colon in four patients, and transverse colon in one patient An 8 or 10F tube was introduced into the proximal dilated bowel through the anus, and irrigation with normal saline was carried out twice a day. Corrective pull-through operation was performed using a modified Duhamel's procedure through a small transverse supra-pubic incision. Results Decompression using the tube was easy and highly effective, and abdominal distention rapidly disappeared in all patients. The mean length of preoperative tubing was 54 days without any complications. The mean age and weight at operation were 705 days and 49 kg, respectively. Major postoperative complications were enterocolitis in two patients, and bowel obstruction in one patient. The mean postoperative stay was 42 days. While the patients' ages now range from 6 mo to 3 yr, three patients have normal bowel habits. Cosmetic results were reported as satisfactory by their parents. Conclusion The one-stage pull-through procedure for HD with this management could be performed safely without colostomy Since the primary transanal pull-through procedure will be used as a main technique for HD in the near future, preoperative decompression and irrigation through the transanal tube will be useful.

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A 6-year-old boy was admitted to our hospital because of a subcutaneous tumor in his right upper arm. The tumor rapidly became large within a 2-week period. Roentogenography showed homogenous mass density without calcification. At the time of ultrasonography, a heterogenous solid mass with an obliterated border between the tumor and the fascia was noted MRI T2 weighted images revealed that the tumor had invaded the fascia An excisional biopsy was carried out due to suspicion of malignancy. The tumor was excised with the involved fascia. Spindle cell sarcoma was histologically suspected at surgery, but no definite histological diagnosis was made until a second opinion suggested nodular fasciitis. The patient is doing well with no clinical signs of recurrence. Nodular fasciitis is a benign reactive proliferation of myofibroblasts, and usually occurs in the forearm of adults. It can be misdiagnosed as a malingnant soft tissue tumor because of clinically rapid growth and highly cellular pseudo-sarcomatous proliferations. At the time of diagnosis of soft tissue tumor in children, nodular fasciitis must also be considered as a possible differential diagnosis to avoid misdiagnosis and overtreatment of this rare tumor.

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We report a rare case of extrarenal Wilms' tumor during childhood. A 2-year-old boy was admitted with a right lower abdominal mass. On physical examination, the mass was large, elastic and fixed CT and MRI showed a tumor coverd with a capsule m the pelvis, without calcification and lymph node swelling. The tumor was separated from the right kidney. Preoperative diagnosis was retroperitoneal tumor. Following the operation, the tumor measurement were 95×80×70 mm and it weighed 234 g The histological diagnosis was extrarenal Wilms' tumor with favorable histology. He was treated with Regimen EE-4A chemotherapy and was free of recurrence after 1 yr and 5 mo.

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Purpose Respiratory management of C-type esophageal atresia sometimes becomes difficult due to air leakage through the tracheoesophageal fistula (TEF). Pediatnc pneumonectomy can also become complicated due to the lack of a device small enough for diverted ventilation. To address these issues, we occluded the TEF or lobar bronchus with a Fogarty catheter through a bronchoscope. These cases were reviewed. Methods/Results We treated five patients with C-type esophageal atresia and eight with cystic lung disease [Tracheoesophageal fistula] Prior to surgery, a Fogarty catheter was inserted into the lower esophagus through the TEF under bronchoscopic observation, and a balloon was inflated. Thereafter, only the bronchoscope was withdrawn, and endotracheal intubation was performed. The Fogarty catheter was removed when the TEF was secured during the surgery. For this bronchoscopic procedure, 56 mm was used on average. With this occlusion, air leakage through the TEF during surgery was completely controlled. [Lobectomy] A Fogarty catheter was placed in the pathologic lobar bronchus The balloon was inflated to prevent purulent sputum from spilling into the normal lobe and prevent the over expansion of cysts. For this bronchoscopic procedure, 75 mm was used on average. With this occlusion expansion of the cystic lesion in the lungs was completely controlled during surgery. Conclusions Occlusion of the TEF or the bronchus using a Fogarty catheter through the trachea is a simple and safe procedure that can maintain stable ventilation during surgical treatment for these diseases.

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