Purpose: The purpose is to determine the characteristics of the patient who requires further evaluation for pathological lesion at the leading point. Methods: One hundred children who were treated on intussusception at our institution from 1987 to 2005 were reviewed. Results: Four out of the 100 children (4%) with pathological lesions were retrospectively analyzed. The lesions were intestinal polyp, malignant lymphoma, anaphylactic purpura and Meckel's diverticulum. The incidence of pathological lesion of the children 5 years of age or older was ten times higher [33.3% (2/6)] than those of under 5 years of age [2.1% (2/94)]. A literature review showed that the incidence of the intussusception with pathological lesions was 3.8% [324 out of 8,559 cases (data from 23 institutions) ]. Reports from 7 institutions referred to the pathological lesion. The cumulative incidence of 5-15 years of age was 36% (41/114). On the other hand, the incidence of those less than 5 years of age was 3.2% (83/2,577). The relative incidence of pathological lesions causing intussusception increases with age. The ratio of malignant lymphoma in the pathological leading point becomes high in older children. More than half of the 7- or 8-year-old patients who presented intussusception with pathological lesion have malignant lymphoma. Conclusion: Even though hydrostatic reduction succeeded, further evaluation is recommended for older children who show unusual status or recur in a short while. Gallium scintiscan is useful for detecting malignant lymphoma.

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Purpose: We reviewed pyloromyotomy with intraumbilical arcuate incision for hypertrophic pyloric stenosis, in which pyloromyotomy was performed in the abdominal cavity without retracting the pylorus outside the abdominal cavity. Methods: Between 1996 and 2007, 76 infants underwent this procedure. We retrospectively reviewed the cases. Results: Male to female ratio was 64: 12. Average age at operation was 43 days. Average operation time was 65 minutes. Postoperative feeding was started at 1.5 postoperative day on the average. Average postoperative hospital stay was 8.2 days. Complications were seen in 4 cases (5.3%), including intraoperative gastric mucosal injury in one case, intraoperative duodenal mucosal injury in two cases and postoperative umbilical disconfiguration in one case. Gastric or duodenal mucosal injury was repaired at the operation without postoperative peritonitis. Umbilical disconfiguration was surgically repaired one year later. Prolonged postoperative vomiting was seen in two cases, which was treated with atropine sulfate. Umbilical skin necrosis or surgical site infection was not seen. Conclusions: Although this procedure needs more meticulous technique than a conventional right upper quadrant laparotomy, postoperative results were satisfactory. We advocate this technique for the standard operation for hypertrophic pyloric stenosis.

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Purpose: Pediatric liver transplant recipients are often infected with human herpesviruses. Cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human herpesvirus 6 (HHV-6) cause sometimes life-threatening infection. Our object was to monitor CMV, EBV, and HHV-6. Methods: From June 2004 to December 2007, 17 pediatric liver transplants were performed in our hospital. CMV were monitored with antigenemia (C7-HRP), EBV were monitored with real-time PCR method, and HHV-6 were monitored with the cytopathic effect of the mononuclear cells. Results: The detection rate of CMV was 8/17 (47.1%), and CMV were detected about one month after transplantation. None of the patients was infected with CMV 90 days postoperatively. The detection rate of EBV was 8/17 (47.1%), and EBV were detected at any time for 30 months after transplantation. Seven of eight patients in whom EBV were detected were in the non-infected group before transplantation. HHV-6 was detected with five patients. Four of them suffered primary HHV-6 infection with the liver graft. All of them had fever, and three of them had decreasing of platelets and liver disfunction, but none of them had the rash after fever. Conclusions: Human herpesviruses are detected at a high rate after pediatric liver transplantation. CMV, EBV, and HHV-6 were detected at 47.1%, 47.1%, 29.4%, respectively. Although many of the patients did not present the symptoms of illness, sometimes critical complications may be caused and the early detection by periodical monitoring is important.

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Background: Cystic lymphangiomas (CLs) are uncommon, benign cystlike conditions characterized by proliferation of tumored lymph vessels. Most are found in the head, neck or extremities, while mesentery and retroperitoneum may occasionally be involved and associated with various clinical problems. We reviewed our patients with such rare abdominal CLs. Methods: Patients with abdominal CLs treated in our institution during the period from June 1996 to September 2006 were reviewed. Results: Eleven patients were listed and their ages ranged from 0 days to 13 years. Nine patients were symptomatic. Symptoms and signs included infections (2 patients), intestinal obstruction (3), and groin mass (3). All were surgically treated. Six CLs were located in the mesentery and likely to have infectious or obstructive signs. The other 5 arose in the retroperitoneum. Mesenteric CLs required concomitant resection of the intestine in 3 patients. In the other 2 patients, lesions were partially left residual to avoid extensive intestinal resection. Of retroperitoneal CLs, 3 lesions involved inguinal regions and had diagnostic problem to discriminate from herniation or hydrocele. There were no major postoperative complications or recurrences. Conclusions: Mesenteric CLs are likely to be presented with intestinal obstruction or infection, and retroperitoneal CLs are often presented with groin mass. Although abdominal CLs are rare, it is necessary to consider CLs in these symptoms. Remedy should consider surgical management with the state of each case.

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We present here a case of a 2-year-old girl with an anterior anal fistula, successfully treated by fisterectomy technique. She was born at 40 weeks of gestation (birth weight: 2,830g), and a perianal abscess was recognized in early infant age and then diagnosed as anal fistula. We performed fisterectomy for anal fistula with satisfactory results. This operation consists of several procedures including a lay open, fisterectomy and closure of the dead space in layers. Although anterior anal fistula in girls is extremely rare and there is not a standard procedure, this operative method is considered to be a feasible technique for female anal fistula.

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A five-month-old boy was admitted to our hospital for vomiting and lethargy. Abdominal distention and respiratory distress were rapidly progressive. A large amount of air was detected under the diaphragm by abdominal radiography, which resembled the saddle-bag sign. An emergency laparotomy revealed a nonulcerate gastric rupture with a diameter of 5mm in the anterior wall near the greater curvature. The rupture was simply closed after trimming of the abnormally thin wall around the hole. Microscopic examination of the thin portion showed a defect of the tunica muscularis. The cause of the rupture in this case was considered to be a congenital defect of the muscular layer in the gastric wall.

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This is a case report of a female neonate with gastroschisis associated with congenital small intestinal atresia. At birth, she was found to have a protruded intestine from the stomach to the transverse colon and interrupted atresia at 70cm distal from the pylorus and 1cm proximal from the ileocecal region. Because the extruded intestine was edematous, and the caliber of dilated proximal intestine was six times larger than that of distal ileum, primary anastomosis was avoided and the abdominal wall closure with double-barrel enterostomy was performed. After dilation of the colon by continuous saline injection to the distal stoma, enterostomy was closed at 44 days of life. The postoperative course was uneventful and she well tolerated full feeding at 4 months of age. Management for gastroschisis associated with atresia of gastrointestinal tract remains controversial, and it depends on the location of the atresia. Staged operation with primary enterostomy at the abdominal wall closure followed by stoma closure is recommended for cases with distal ileal or colonic atresia, since it may prevent anastomotic leakage and stenosis.

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A 27-day-old girl exhibited an abdominal cyst by fetal ultrasonography. After birth, expansion of the cyst was detected on ultrasonography, and the greatest transverse diameter was about 3cm. She excreted bile stool. Accumulation from the liver to the common bile duct, and subsequently to the exterior of the right common bile duct, was evident with bile duct scintigraphy (^<99m>Tc-PMT). Although direct bilirubin level increased to 3.0mg/dl from birth to the 14th day and the diameter of the common bile duct increased to about 5cm on ultrasonography, she remained afebrile and excreted bile stool. When surgery was performed on the 27th day of age, a small amount of bile-colored ascites and bottle green liver was found. Severe adhesion was present in the common bile duct, especially the lateral part, and penetration to the retroperitoneal space (about 5mm in diameter) was present in the common bile duct. Excision of the expanded bile duct and hepatic duct jejuni Roux-en Y anastomoses were performed. For neonates, the bile duct is at great risk of perforation due to fragility of the biliary system. Therefore if the symptoms suggest the possibility of perforation, such as an increase of direct bilirubin value and common bile duct diameter, we should perform an operation immediately.

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This report describes the case of a 6-year-old girl with cystic lymphangioma of the round ligament of the liver. She presented with an abdominal cyst found by ultrasonography (US) following mild abdominal pain. US, computed tomography and magnetic resonance imaging revealed a 2.5×10cm, sharply defined cystic lesion with internal septa from the subhepatic area below the umbilicus. The cystic lesion was diagnosed to develop from the round ligament of the liver based on the anatomical location and imaging findings. A complete excision of the lesion was performed by laparoscopic-assisted surgery. A pathological examination confirmed the diagnosis of a cystic lymphangioma. Cystic lymphangioma of the round ligament of the liver does not appear to have been previously reported in a review of the Japanese and English literature.

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