Purpose: The purpose of this study is to evaluate effectiveness of adhesive strapping in the treatment of infantile umbilical hernia by comparing it with conservative observation. Subjects and methods: The subjects consisted of infants who visited our hospital during October 2000 through January 2005 for umbilical hernia and who were aged up to six months at the first visit, and who could also be observed up to two years old or whose recovery could be confirmed before the age of two. Variables including recovery rate and term until recovery were compared between the two treatment groups: conservative observation (cases up to December 2002) and adhesive strapping (cases after that). For statistical analysis, the t-test and Fisher's exact probability test were used, with the significance level at p<0.05. Strapping was conducted by reducing the umbilical hernia manually, pulling the nearby skin laterally or vertically, and fixing the area with an elastic strap. Results: Of 32 cases in the conservative observation group, 25 recovered, 1 had surgery. Of 32 cases treated with adhesive strapping, 28 recovered, 1 had surgery. The recovery rate was 78.1% in the conservative observation group and 87.5% in the adhesive strapping group with no significant difference. In the cases which recovered, the adhesive strapping group recovered at significantly (p=0.0025) earlier ages than conservative observation group. Conclusion: Adhesive strapping to treat infantile umbilical hernia seemed to be effective for earlier recovery.

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Purpose: Because of the advance of ultrasonography, congenital biliary dilatation (CBD) has been diagnosed in early infancy. The appropriate time for an operation is not clear in these cases. We reviewed the cases in which we operated during infancy in terms of pathology tissue and considered the most appropriate timing of surgery. Methods: Eight infants underwent the primary definitive surgery, between March, 2005 and January, 1981. We evaluated the degree of fibrosis of liver and the time of surgery. Results: Of these 8 patients, 3 patients waited for 3-5 months, and received the primary definitive surgery, and 5 patients underwent early definitive surgery. The age at the surgery ranged from 47 days to 7 months. Liver histology showed fibrosis in 5 cases out of 8. The follow-up period ranged from 11 years 6 months to 4 months. Now, liver function is normal for all cases. Discussion: The optimal strategy of management for CBD in a fetal case and early infancy case has not established. Suita and Burnweit stated prompt surgical intervention should be done. However, in asymptomatic cases in which liver function tests are normal, Otsuka and Redker stated elective definitive surgery should be carried out by 3 months. Okada proposed delayed primary definitive surgery should be done by 6 months. We propose that infants with evidence of deteriorative liver function, progressive enlargement of the cyst, and development of obstructive jaundice, should undergo early definitive surgery, and infants with asymptomatic CBD should be monitored closely with ultrasonography and liver function tests. They should undergo elective surgery at 3 months of age.

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Background: It is to research the validity of medical strategy and the importance of excluding biliary atresia (BA) from metabolic cholestasis in premature infant. Methods: We investigated retrospectively the clinical data for two premature neonates; one was an extremely low birthweight infant with BA (case 1) and the other was a very low birthweight infant with metabolic disorder of bile acid (case 2). We analyzed the justification of the clinical strategy and the medical management through various tests. Among the recipients who underwent pediatric living donor liver transplantation (LDLT) at Kyoto University Hospital starting in June 1990, the number of the recipients less than 5kg in body weight at pediatric LDLT was 20 cases (5 boys: 15 girls). We evaluated the survival rate, the morbidity, and the mortality in the recipients. Results: Case 1 died due to multiple organ failure on the 36th postoperative day. Case 2 takes further investigative studies and medical management. Of 20 recipients, 10 survived and 10 died. All five recipients less than 3.7kg in body weight at pediatric LDLT died, and the survival rate of the recipients more than 3.8kg in body weight was 66.7%. Conclusion: It is important for the premature infants of metabolic cholestasis to rule out BA by means of ultrasound study or radioisotope scintigraphy. Pediatric LDLT should be taken into consideration in case of the optimal chance of Kasai's procedure being missed or progressing unknown liver cirrhosis.

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Purpose: We investigated the methods for preventing complications of the Nuss procedure for pectus excavatum. Methods: Fifty-two patients who included 39 males and 13 females (2-24 years of age) underwent the Nuss procedure. From among these patients, a total of 29 bar removals were done in 28 patients. We investigated early and late complications after the Nuss procedure, and complications related to bar removal. Results: There were early complications in 8 patients. These included atelectasis along with pleural effusion and high fever in 5 patients, flipping of a bar in 3 patients, sternal fracture in 1 patient, and tension pneumothorax due to lung injury in 1 patient. Late complications were observed in 2 patients. One male patient experienced sudden severe chest pain 6 months after the Nuss procedure. A chest roentgenogram revealed right pleural effusion. Another male patient presented at the hospital with complaints of sudden chest pain and dyspnea 12 months after the Nuss procedure. The wires that fixed the bar to the ribs were found to be broken. These wires injured the right lung and caused tension pneumothorax. Furthermore, a part of the wire had dropped into the pleural cavity as a foreign body. Complications related to bar removal occurred in 7 patients. These included wire pieces that were retained as foreign bodies in 3 patients, bleeding from the intercostal artery in 1 patient, injury to the pericardium in 1 patient, pneumothorax in 1 patient and a bar buried under the ribs in 1 patient. Conclusion: In our study, the center of the bar was kept flat, 2 stabilizers were attached to the bar bilaterally, and both the edges of the bar were fixed to the ribs by using thick unabsorbable strings. After this method was introduced, flipping of a bar was not observed. The severe pain that follows the Nuss procedure should be adequately relieved, and patients should be mobilized as early as possible to avoid atelectasis. We highly recommend that the bilateral pleural cavities should be carefully observed to avoid organ injuries and bleeding, and the bar should not be fixed with wires. To prevent complications related to bar removal, surgeons should consider using a bar without indents and straighten the edges of the bar. We also recommend that the bar should not be kept in the body longer than necessary because the bar prevents the growth of the bony thorax in children.

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A two-year-old girl complained of pharyngeal pain after digesting a flounder. She had a high fever and a cough. Despite antibiotic treatment, she developed inspirative stridor and airway obstruction developed thereafter. She was intubated immediately and supported with a mechanical ventilator. After transfer to our hospital, CT scan and US revealed a retropharyngeal abscess which caused airway obstruction. Surgical drainage was performed and a fish bone in the abscess cavity was removed under general anesthesia. Although fish bones are a common pharyngeal foreign body, airway obstruction due to retropharyngeal abscess caused by a fish bone is very rare. CT scan and US are simple and reliable methods for immediate diagnosis of retropharyngeal abscess, and useful to avoid complications.

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A ten-year-old boy with epilepsy was referred to our hospital with a psammous calcification in the left upper quadrant detected on plain X-ray. Abdominal ultrasound revealed a 5-cm hypoechoic mass in the spleen. The tumor was densely enhanced in the early arterial phase, and equally enhanced in the venous phase on contrast-enhanced computed tomographic images. In view of the enhancement of the splenic veins in the arterial phase on contrast-enhanced computed tomography, it was presumed there was a risk of portal hypertension and rupture of the mass, and laparoscopic splenectomy was performed with preservation of an accessory spleen. Histological examination revealed a splenic hamartoma consisting of red pulp components.

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Rupture is one of the rare complications in choledochal cysts, and the first treatment including primary operation or external drainage is still controversial. We reported a case of biliary peritonitis in an 11-month-old girl due to a ruptured choledochal cyst. She was referred with vomiting and diarrhea to our hospital. Laboratory data revealed jaundice and hyperamylasemia. An abdominal computed tomography showed the dilated common bile duct and markedly increased ascites. Bile leakage from the extrahepatic bile duct was easily found by ^<99m>Tc-PMT scintigraphy. She was diagnosed with a ruptured choledochal cyst and underwent emergent laparotomy. During surgery, a large perforation in the anterior wall of the choledochal cyst was found and intraoperative cholangiography showed pancreaticobiliary maljunction with a protein plug in the common channel. Primary cyst excision and biliary reconstruction were successfully performed, and the postoperative course was satisfactory. Biliary scintigraphy is a noninvasive and useful diagnostic modality and primary operation may be one of the preferred therapeutic options in the management of ruptured choledochal cysts.

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An extremely low-birth-weight male infant with gastroschisis was delivered at 27 weeks' gestation and 736g via Cesarean section due to non-reassuring fetal status. A chromosomal abnormality was suspected when the baby was noted to have low-set ears, micrognathia, syndactyly and clubfoot. The family opted for non-operative treatment of the gastroschisis. We performed sutureless abdominal wall closure with Tegaderm in the neonatal intensive care unit. The eviscerated bowels were successfully reduced without anesthesia after careful inspection, and the abdominal wall defect was narrowed with Steri-strips. The narrowed defect was then bridged with the umbilical cord and covered with a Tegaderm film. The proce dure was finished in 10 minutes with the patient remaining stable throughout. The Tegaderm dressing was changed on day 4, 6 and 13. The spontaneous abdominal wall closure was confirmed on day 13, and the Tegaderm dressing was removed on day 20. The patient was discharged at 5 months of age, weighing 2.4kg. The abdominal wall defect was closed with a centrally located umbilicus and an umbilical hernia. This procedure can be safely performed especially for extremely low-birth-weight infants with minimal intestinal edema, since it is minimally invasive and does not require general anesthesia. Under general anesthesia or intravenous injection of sedatives and muscle relaxant this procedure may be performed for infants with gastroschisis even with edematous intestine.

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We report a case of delayed onset spinal cord injury with abdominal trauma after a motor vehicle accident. A 3y8m girl was involved in a motor vehicle accident when she was not noticed by a driver as he backed his vehicle out of a parking space. She had abdominal discomfort and pain, and slight hypoaction. Frexture, paralysis, and unconsciousness were not found. Her conscious was clear with no sign of fracture or paralysis. A CT scan revealed liver laceration and splenic injury. Her vital signs were stable and she was admitted to our hospital for close observation and bedrest. On hospital day 3, she suffered bilateral leg paraplegia, and the neurological level was upper thoracic vertebrae. Radiologic findings including X-ray, CT, and MRI did not reveal fracture nor spinal cord injury, and this case was thought to be compatible with spinal cord injury without radiographic abnormality (SCIWORA). Rehabilitation were performed and on hospital day 7, she could move her toe spontaneously. On hospital day 12, she could stand and work her shoulder by herself. About 3 months later, she could run, and 10 months later she had completely recovered from paraplegia successfully.

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We report a 5-month-old boy with congenital cystic adenomatoid malformation (CCAM) associated with an aberrant artery originating from celiac trunk. He developed respiratory symptoms, and was referred to our hospital because of abnormal findings in the chest X-ray. CT scan demonstrated a multicystic lung lesion in the right lower lobe and the aberrant artery approaching from celiac trunk to the affected lobe through the esophageal hiatus. No bronchial abnormality was found; thus, association of pulmonary sequestration was excluded. Right lower lobectomy was successfully performed using the video-assisted thoracoscopic surgical approach. The lung specimen was pathologically diagnosed as CCAM, Stocker type I. The postoperative course was uneventful.

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A case of an 11 year-old boy with a retrocaval ureter underwent retroperitoneoscopic surgery. The patient had complained of right lumber pain for a year and ultrasonography revealed right hydronephrosis at a previous hospital. We made a diagnosis of retrocaval uteter using enhanced CT scan and retrograde contrast study. An operation was performed under retroperitoneoscopy. We amputated the proximal dilated ureter, dissected the distal ureter from the vena cava, moved it from the back to front, and performed extracorporeal uretero-ureteral anastomosis. After the operation, the patient's progress has been uneventful with a complete recovery of hydronephrosis. Retroperitoneoscopic surgery with extracorporeal anastomosis of the ureter can be indicated for retrocaval ureter.

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A 3-year-old boy was referred to our hospital because of prolonged abdominal pain and bile-stained vomit. CT, MRI and ultrasonographic examination demonstrated a huge cystic mass in the left upper abdominal quadrant. The cystic mass was strongly suspected to be a mesenteric cyst, and laparotomy was undertaken. However, the laparotomy revealed that the mass was organized as a huge intramural hematoma of the jejunum (16.5cm×6.3cm×5.0cm), which was successfully resected. Children with an intramural hematoma of the intestine resulting from blunt and sometimes vague trauma do not present in a clear manner. It is hard to distinguish a hematoma with hydropic degeneration from a mesenteric cyst even with CT, MRI and ultrasonographic examination. The vast majority of reported cases in which an operation has been performed required only evacuation of the hematoma through a serosal incision. But in cases whose hematoma is organized, resection of the involved portion should be employed, because incomplete evacuation may invite delayed stenosis of the intestine. This prompted us to question routine nonoperative management and think that operative intervention may be more appropriate in some instances, particularly when lengthy periods of supportive treatment would be necessary.

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Annular pancreas (AP) results from a developmental anomaly of the pancreatic buds. In children, AP is a recognized cause of duodenal obstruction, and chronic pancreatitis is rare. We present a case of chronic pancreatitis after surgery for duodenal stenosis due to AP. A 6-year-old boy with recurrent pancreatitis was admitted to our hospital. He underwent a duodeno-duodenostomy for duodenal stenosis with AP at 3 days after birth. CT and MRI showed a dilated pancreatic duct and pancreatic stones. Intraoperative cholangiography obtained through the gallbladder and the major duodenal papilla (Vater papilla) showed only the bile duct without dilatation. Cannulation of the pancreatic duct through the minor papilla demonstrated a stenotic segment of the pancreatic duct in the AP, and a dilated main duct in the body. The pancreatic duct ran around the duodenum, and flowed into the minor papilla without communication with the Vater papilla. He was treated by a modified Frey procedure, with sphincteroplasty and cholecystectomy. Hypoplasia of the ventral pancreas and overgrowth of the dorsal pancreas may have played a role in the development of annular pancreas in this case. In children with AP, it is necessary to consider the possibility of pancreatobiliary disorders.

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A 16-year-old female was admitted to our hospital because of symptoms of upper abdominal pain and back pain. Ultrasound sonography, a computed tomography scan, magnetic resonance imaging and angiography revealed a mass measuring 104×79mm in size in the pancreatic head. The tumor was completely covered with a fibrous capsule and a total excision was thus performed. Although the pancreatic pseudocyst demonstrated some complications after the operation, total parental nutrition and the administration of pancreatic enzyme-inhibiting agents proved to be effective. No recurrence of either SPT or the pancreatic pseudocyst have occurred during the 30-month period after surgery. A solid-pseudopapillary tumor often occurs in young women; however, such tumors tend to have a good prognosis. Regarding the optimal operative method for SPT arising in the pancreatic head, a total excision of the tumor instead of a pancreatoduodenectomy is therefore recommended in relatively young patients.

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A male neonate presented with upper airway obstruction soon after birth, and he was referred to our hospital. When endotracheal intubation was performed, a globular white tumor covering the glottis was found, so a diagnosis of upper airway obstruction due to laryngeal cyst was made. Endotracheal intubation could be completed and his upper airway obstruction was relieved. On day 13 of life, the tumor was marsupialized by endoscopic surgery. After insertion of an endoscope orally, the cyst wall was removed using endoscopic forceps and a cautery knife. Extubation was done 2 days after surgery and he has been free of symptoms for 3 months since the operation. Neonates can easily develop airway obstruction due to a laryngeal cyst because of their relatively small airways. Therefore accurate diagnosis and treatment must be provided immediately.

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