Purpose : There are no guidelines for routine preoperative examinations in children undergoing elective minor surgery and the examinations performed are different depending on hospitals. To know whether routine examinations prior to elective minor surgery are necessary, we investigated the usefulness of the examinations. Materials and Methods : The results of routine laboratory blood tests, urinalysis, chest X-ray and electrocardiogram (ECG) performed preoperatively in 1,069 admissions of 1,005 patients were analyzed. The reasons for cancellation of surgery and perioperative complications were also examined. Results : A total of 33 surgeries were cancelled (3.1% of 1,069 admissions) and the reasons were upper respiratory tract infections in 29 patients, social reasons in 2 patients, and hepatitis and iron deficiency anemia in one patient each. The diagnoses of the last two illnesses were made by the results of laboratory blood tests. Surgery was cancelled in 10 patients with elevated CRP, all of whom had symptoms of upper respiratory tract infections. No surgery was cancelled due to the findings of urinalysis, chest X-ray or ECG. Although one patient had hypertension during and after surgery, there were no complications related to the findings of preoperative examinations. Conclusions : Evidence showing the benefits of routine preoperative examinations was scant. A thorough clinical assessment with necessary examinations may be substituted for routine examinations without compromising the safety of anesthesia and surgery in children undergoing elective minor surgery. Urinalysis and ECG are unnecessary and laboratory blood tests should be limited to blood count, liver enzymes and infection survey.

View full abstract

Purpose : Congenital diaphragmatic hernia (CDH), especially prenatally diagnosed, remains an unsolved problem in neonatal surgery. To evaluate the effect of gentle ventilation for neonates with CDH, we established a new protocolized approach to the management in our institution. Materials and Methods : Twenty-one patients with prenatally diagnosed CDH were treated at Children's Research Hospital, Kyoto Prefectural University of Medicine from 1992 to 2005. These 21 patients were divided into 2 groups : Group 1, 13 patients from 1992 to 2002 who had conservative therapy with hyperventilation, muscle relaxants, and unlimited mean airway pressure. Group 2, 8 patients from 2003 to 2005 who had a new protocolized management with gentle ventilation, steroid, diuretic, and surfactant. Results : These two groups were compared with respect to risk factors such as age at diagnosis, gestational age, birth weight, method of delivery, overall anomalies, severe cardiac disease, side of hernia, stomach and liver in chest, area of defect, and patch repair. There were statistically no differences between these 2 groups. Seven of the 8 patients (88%) receiving gentle ventilation survived, and six of the 13 patients (46%) receiving conservative therapy survived. However, there was no significant difference in the survival between the 2 groups. Total ventilator days, ventilator days after operation, and duration of hospitalization in the gentle ventilation therapy were significantly shortened, compared with those in the conservative therapy. Conclusion : In the management of neonates with highrisk CDH, gentle ventilation might be effective because of less iatrogenic ventilator injury.

View full abstract

Purpose : To determine whether addition of power Doppler ultrasonography (US) to grayscale US is useful in evaluating appendicitis in children. Methods : In a retrospective study, grayscale US findings were evaluated in 100 children. Power Doppler US was also done in 15 children. Criterion for appendicitis was a diameter of the appendix exceeding 6mm. Ultrasonographic findings of acute appendicitis were classified into 3 grades based on the appearance of intramural appendiceal structure (grade I : clear wall structure, grade II : unclear wall structure, grade III : loss of wall structure). Findings of power Doppler US were also classified into 4 grades (none, low, moderate, and high blood flow). Results : In grayscale US, 15 children were grade I. Sixty-six children were grade II and 19 were grade III. Appendectomy was performed in 73 cases. In all operated cases, pathological diagnosis was appendicitis including 2 (2.7%) catarrhal appendicitis. All grade I cases were conservatively treated. In grade II, 12 cases were treated conservatively and 54 cases were operated on. All 19 cases in grade III were operated on. In 15 cases which were examined by power Doppler US, 8 cases were treated conservatively. Five of them in grade I of grayscale US showed low blood flow and 3 cases in grade II showed high blood flow. In the remaining 7 cases who underwent surgery, none of them showed high blood flow. Conclusions : Addition of power Doppler US to conventional grayscale US improved the accuracy in determining the surgical indication of acute appendicitis.

View full abstract

Purpose : Survival rate of patients with congenital esophageal atresia (CEA) has been improved. However, in Japan, few investigations about long-term outcome beyond 16 years have been reported. We investigated the outcome of our patients from the physical and social point of view. Materials and Methods : We investigated 16 patients among 42 surviving patients who underwent repair of CEA from 1967 to 1989. The information regarding physical and social status of 16 patients (male 9, female 7) was obtained from clinical charts and questionnaire data. Results : The mean age of patients was 22.9 years old (16 to 31). The mean body mass index (BMI) of male patients and female were 21.7 and 19.4, respectively. Three female patients had lower BMI and complained of gastrointestinal symptoms during a meal. Six patients suffered from gastrointestinal symptoms such as hold-up. Four patients had heart burn probably caused by gastroesophageal reflux disease. Respiratory symptoms were found in 4 patients including 2 patients with tracheomalacia. Of 16 patients, 8 were working and 7 were students. Three patients were married and had healthy children. Conclusion : Our study indicates that the social quality of life of patients was good. However, observation and treatment of some patients is necessary because they had continuous unhealed gastrointestinal and/or respiratory symptoms.

View full abstract

We report a case of neuroblastoma associated with opsoclonus-myoclonus-ataxia (OMA) syndrome. At 20 months of age, a previously healthy girl developed gait disturbance, tremor and nystagmus. At 24 months of age, she was referred for treatment to Kansai Medical University. Serum level of NSE and urine levels of HVA and VMA were elevated. Abdominal ultrasound and CT showed a 4-cm mass in the right adrenal gland. Metastatic workup by bone scan, MIBG scintigraphy, bone marrow aspirates and biopsies, and head CT were negative. The adrenal tumor was removed. Histological examination confirmed neuroblastoma, unfavorable histology. No N-myc amplification with high Ha-ras or trk A was revealed. Three weeks after surgery, most of the neurological symptoms disappeared. Four weeks after surgery, 6 courses of James' chemotherapy were performed. She has been well with residual intermittent ataxia with no tumor recurrence In the review of the Japanese literature, 40 patients had been reported as having neuroblastoma associated with OMA. OMA is a rare paraneoplastic or paraviral neurological syndrome. In children, OMA is most commonly associated with neuroblastoma, occurring in 2-3% of all children with this tumor. It is defined as acute onset of rapid and chaotic eye movements, myoclonic jerking of the limbs and trunk, and ataxia. While children with OMA and neuroblastoma most often display favorable prognosis tumor characteristics and a high survival rate, many also experience devastating developmental delays and nervous system dysfunction.

View full abstract

We experienced a pulmonary solid tumor in a one-year-old girl. Pleural indentation was observed on MR imaging, so we suspected a malignant tumor. But the tumoral size decreased during 2 months. The tumor was localized in S6 of the right lung, so we excised it without remnant by segmental lobectomy. Pathological diagnosis was pulmonary inflammatory pseudotumor. This case had a history of recurrent respiratory infection, and an abnormal shadow appeared on a plain X-ray for the first time on examination for uncommon fever. Preoperative diagnosis of this disease is difficult, so almost all cases are diagnosed by excisional biopsy. We think that strict postoperative observation is necessary, because of the possibility of recurrence.

View full abstract

A case of the first branchial cleft cyst seen in a 14-year-old girl is reported. She was noted having an infraauricular cyst at 11 years of age and referred to us because of slow enlargement. She had not experienced redness, swelling or tenderness of the cyst. Clinical examination demonstrated a non-tender, elastic soft and immovable cystic mass with a clear margin. A puncture of the cyst demonstrated squamous epithelium. On surgical resection the cyst wall was very close to the external auditory canal but no fistula was seen. We excised the shallow part of the cyst completely and an only inner layer including all epithelium of the deep part of the cyst to avoid injury to facial nerves. Histopathologically the cyst was lined by squamous epithelium with lymphoid tissue. She had an uneventful postoperative course. Although the first branchial cyst is a rare anomaly, it should be kept in mind when seeing cervical masses in children.

View full abstract

We experienced a case of antenatally diagnosed congenital hepatoblastoma. This patient was categorized into advanced stage, so preoperative chemotherapy was done. After the chemotherapy we completely excised the tumor by extended right lobectomy of the liver. As postoperative chemotherapy we selected the protocol for neuroblastoma, because AFP did not decrease well. Six years after operation, this patient survives without recurrence or metastasis. Congenital hepatoblastoma is rare. We reviewed 22 cases in the Japanese literature, and this is the first case detected by fetal diagnosis.

View full abstract

We herein report two cases of late-presenting congenital diaphragmatic hernia who underwent laparoscopic hernia repair. One was a 2-year-old girl and the other was a 4-year-old girl. They were admitted to our hospital because of audible bowel sound at the left thoracic region. Both cases were diagnosed as late-presenting congenital diaphragmatic hernia, and laparoscopic repair was performed. In spite of several difficulties in the laparoscopic procedure, we eventually accomplished the diaphragmatic repair in both cases devising patients' position and trocar arrangement.

View full abstract

A 4-month-old girl presented pus discharge from a tiny midline opening over the pubic symphysis. There were no other symptoms nor evidence of infection. A fistulography revealed a tract that extended from the skin into the neck of the bladder and ascended toward the umbilicus but communicated with neither of them. A surgical procedure was undertaken. The tract went deep toward the symphysis pubis and ascended toward the umbilicus, parallel to the median umbilical ligament. The infraumbilical tract ended blindly 1.5cm caudal to the navel, where it was excised. The histological examination demonstrated transitional epithelium.

View full abstract

[in Japanese]

View full abstract