Purpose: We reviewed cases of cholestasis in infants to investigate the indications and effects of biliary lavage.
Methods: We retrospectively reviewed the clinical features and treatments performed in 9 patients who presented with pale stools and direct hyperbilirubinemia in early childhood. The patients were treated between May 2005 and April 2009.
Results: Intraoperative cholangiography was performed in 5 patients (cholangiography group). In 4 of these patients, an obstruction of the common bile duct was resolved with repeated biliary saline lavage (biliary-lavage group): 2 cases improved rapidly while the remaining 2 cases were improved using steroid pulse therapy. Medication was effective in treating the other 5 cases (non biliary lavage group). In the biliary-lavage group (n = 4), long-term fasting was enforced and total parenteral nutrition was administered, and by performing imaging tests of the biliary tract, we observed abnormal findings such as biliary dilatation, debris, and stones. However, these findings were not observed in the non biliary lavage group (n = 5).
Conclusions: In patients exhibiting abnormal findings of the biliary tract caused by long-term fasting and total parenteral nutrition, biliary lavage should be recommended.

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Purpose: Intussusception is one of the most common causes of bowel obstruction in infancy and childhood. About 20% of the cases require operative reduction after failing enema reduction. We started a laparoscopic approach from 2008, and reviewed our experience of this approach in the management of intussusception.
Methods: A retrospective analysis was conducted for all patients undergoing surgical reduction for intussusception at our institution from October 2008 to October 2011. We evaluated the patient's demographics, diagnosis, conversion to laparotomy, and complications.
Results: There were 76 cases of intussusception. Hydrostatic reduction was carried out in all 76 cases and was successful in 60 (78.9%). In 16 cases, operative reduction was required. One of these cases, which had an ileal perforation at the enema, underwent open laparotomy. Laparoscopic reduction was attempted in 15 and was successful in 10 (66.6%) cases. Two of these 10 cases had ileoileal intussusception with malignant lymphoma as the lead point. Laparoscopically assisted segmental ileal resection was performed extracorporeally, exteriorizing the ileum through an extended umbilical incision. Five cases could not be reduced by laparoscopy. Three of five cases could be managed via extension of an umbilical incision, while 2 necessitated conversion using a right-lower quadrant incision. As these 5 cases could not be reduced by open Hutchinson's maneuver, all cases were resorted to bowel resection. Operative findings revealed intestinal necrosis in three cases: the lead point as malignant lymphoma in one and Meckel's diverticulum in another one.
Conclusion: Intussusception can be treated using a laparoscopic manner for stable patients requiring surgical intervention. Laparoscopic reduction of intussusception is feasible and safe.

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Purpose: We have been actively carrying out transcatheter arterial embolization (TAE) for children suffering from traumatic splenic injury associated with extravasation and pseudoaneurysms. Many cases could be successfully managed with conservative treatment with TAE.
Methods: From January 1996 to December 2011, 27 cases aged less than 15 years were transferred to the emergency room in our institute because of traumatic splenic injury. They consisted of 23 boys and 4 girls; and their average age was 8.4 years old (age range: 1 to 13 years). Nineteen cases had only splenic injury, and 8 cases were associated with multiple organs injury. Their clinical data were investigated.
Results: According to the Surgery of Trauma 2008 of the Japanese Association, the severity was categorized as Ia (n = 1), Ib (n = 2), II (n = 3), IIIa (n = 5), and IIIb (n = 16). Only 1 (IIIb) needed laparotomy, 11 (IIIa: 4, IIIb: 7) underwent angiography, and 5 (extravasation: 3, pseudoaneurysm: 2) cases were treated with TAE. In all cases, bleeding was successfully controlled and well managed conservatively, except for the laparotomy case. Cases with only splenic injury were intervened with either TAE (n = 4) or conservative treatment (n = 15): the Hb values were 10.5 ± 3.1 and 11.7 ± 1.4 g/dl (p = 0.244), and the revised trauma scores were 7.58 ± 0.5 and 7.75 ± 0.3 (p = 0.350) in the former and latter during hospitalization, respectively. However, the injury severity scores of the former (14.0 ± 3.8) was significantly (p = 0.004) higher than that of the latter (7.93 ± 2.0).
Conclusion: Even in cases having splenic injuries with extravasation and pseudoaneurysms, TAE provided bleeding control and favorably treated the patients without surgery.

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Gastroschisis with intestinal atresia can be difficult to treat. We report a case of gastroschisis with intestinal atresia treated with sutureless closure and ileostomy. A neonate diagnosed with gastroschisis had to be delivered by emergency caesarean section at gestation 37 weeks because of uterine contractions. At birth, he was found to have a protruded intestine and triple interrupted atresia at the ileocecal region. Primary anastomosis was avoided, and ileostomy was performed to evade complications such as anastomotic perforation or stenosis, because the extruded intestine was edematous and the caliber of the dilated proximal intestine was large. The sutureless abdominal wall closure by umbilical cord coating was performed with an artificial stoma to facilitate management. There was no event during the postoperative progress. The treatment of gastroschisis with intestinal atresia varies; however, the choice of method in consideration of complications and care is necessary. Staged operation with primary enterostomy of the sutureless abdominal wall closure by umbilical cord coating is one of the choice methods.

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Volvulus of the transverse colon is a very rare condition and patients often suffer from this condition with cerebral palsy and mental retardation. We report a case with volvulus of the transverse colon in a severely handicapped infant with trisomy 13. A 3-year-old boy was admitted to the social welfare corporation because of mental retardation. He usually used a laxative because of chronic constipation. He was referred to our hospital because of abdominal distention and bilious vomiting. He was then admitted to emergency surgery on diagnosis of a strangulated ileus. During the operation, volvuli of the transverse colon and mobile cecum were encountered. The necrotic colon was resected and end-to-end anastomosis was performed. The cecum and ascending colon were fixed to the retroperitonium to prevent recurrence of the volvulus. His postoperative course was uneventful and he was transferred back to the previous hospital on postoperative day 15. Twenty-four months later he had been asymptomatic. The treatment strategy of this disease is either an nonoperative approach, such as the use of barium enema and colonoscopy, or surgery. It is nescessary for us to resect and fix an elongated colon for recurrence prevention, and execute colostomy when the patient's underlying disease is taken into consideration.

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Fetal thoracoamniotic shunting (TAS) is a promising treatment for fetal hydrothorax. However, displacement of the shunting catheter is one of the major complications. We experienced removal of a catheter that had remained in the thoracic wall of a patient.
A 44-day-old girl received TAS for bilateral hydrothorax at the age of 31 weeks and 1 gestational day. However, she underwent bilateral TAS again two days later because of reaccumulation of pleural effusion. She was born at 31 weeks and 6 gestational days by caesarian section due to accumulation of left pleural fluid and decreased fetal heart rate. A catheter was observed on her right chest wall, whereas another was palpated subcutaneously after birth. Chest CT was taken at age 43 days, and removal of the remnant catheter was done one day later. Two incisions were made on the right lateral and dorsal thoracic wall, and muscular tissues that grew into the basket portion of the catheter were dissected bilaterally. No intra- and post-operative complication was observed. Pre-surgical investigation for location of the remnant catheter with CT and dissection of intra-basket muscular tissues might have contributed to uncomplicated removal of the catheter.

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We report a case of prune-belly syndrome (PBS) treated with laparoscopic-assisted abdominal wall plication. A 12-year-old boy, diagnosed with PBS, presented with right lateral abdominal wall deficiency and underwent abdominal wall reconstruction. During the operation, a 5 mm trocar was inserted through an umbilical incision. When the abdomen was insufflated at 10 mmHg CO₂, a bulged area was observed in the right lateral abdominal wall. The skin around the top of the abdominal wall bulge was incised. The skin and subcutaneous tissue were lifted off the abdominal wall until the normal muscles were seen. The fascia were grasped with Allis clamps and vertically plicated by using non-absorbable materials. This abdominal procedure was performed under laparoscopic guidance with care to avoid bowel injury. The drainage tube was placed in the subcutaneous region and excess abdominal skin was removed. Abdominal plication is a simple and highly effective approach for the management of abdominal wall deficiency with PBS. Laparoscopy-guided procedure improved the safety and efficacy of abdominal plication. We recommend that laparoscopic-assisted abdominal wall plication should be considered as an effective approach for the treatment of PBS.

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In adult patients, the effectiveness of purse-string skin closure (PSC) following stoma reversal in terms of infection control and cosmetic outcome has been reported. However, few pediatric cases had been reported. We report a nine-month-old boy who underwent PSC following stoma reversal. The patient previously underwent colostomy at one-day-old and posterior sagittal anorectoplasty at age six months for anal agenesis without fistula. On stoma reversal, the circumferential skin incision was made around the stoma and the stoma was taken down, reconstructed and returned to the peritoneal cavity. The peritoneum and muscles were closed in the ordinary fashion. Purse-string subcuticular suture by 3-0 Nylon was perfromed, leaving a 5 mm defect at the center of the wound. The wound was well healed, leaving about half the length of the stoma diameter without infection. PSC following stoma reversal in pediatric patients is a useful technique with an appealing cosmetic outcome.

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A female neonate, 22 days after birth, was examined due to swelling of the right neck as the primary symptom. MRI showed a cystic mass of about 60-mm long, stretching from the right neck to mediastinum. Since the mass tended to enlarge, surgery was performed 9 months after birth. Prior to surgery, rigid bronchoscopy was carried out, and she was diagnosed with right piriform sinus fistula. A guide-wire was placed in the fistula lumen, and the fistula and cyst were completely resected by a right collar incision of the neck. Right vocal cord paralysis occurred as a postoperative complication.
Piriform sinus fistula, although rare, is a differential diagnosis of a cystic mediastinal mass that extends to the neck. In its surgical treatment, attention must be paid to avoid injury of the laryngeal recurrent nerve.

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We report two cases of arteriovenous malformations (AVM) of extremity and shoulder for which intravascular therapy was effective.
Case 1: A 15-year-old boy presenting shoulder pain. When he was 13 years old, he felt radical shoulder pain with movement of the right upper extremity which eventually led to difficulty in raising the affected extremity. When he was 14 years old, the progressive symptoms were diagnosed as vascular lesions by contrast-enhanced computed tomography scanning, and he was then referred to our hospital. He was diagnosed with AVM because of the existence of a nidus around the right shoulder blade. The symptoms were improved after transarterial embolization (TAE) was repeated for three times.
Case 2: A 15-year-old girl presenting femur pain. When she was 3 years old, swelling at the back of the femur was noted. When she was 11 years old, she felt pain of the affected site for the first time. She was diagnosed as having AVM, and was referred to our hospital. We performed intravascular therapy involving vascular embolization or sclerotherapy for three times, and the symptoms improved with the nidus reduced significantly.
Improvement of symptoms is a very important outcome of the AVM therapy. Since intravascular therapy involving TAE or sclerotherapy is minimally invasive and can be performed repeatedly, its application for the improvement of AVM, especially in children, is emphasized in this study.

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Two cases of contralateral normal ovary torsion after adnexectomy or ovarian cystectomy were reported. Case 1 was an 11-year-old girl, who had a left adnexectomy for torsion of the normal ovary at 6 years old. She was referred to our hospital due to right back pain that persisted for 17 days. On admission, the right ovary (3-cm diameter) had been detected by abdominal CT. The back pain had continued and the second CT scan showed the right ovary had enlarged to 7 cm in diameter. Emergency laparotomy revealed that the right was twisted and necrotic, right adnexectomy was therefore performed. Case 2 was a 15-year-old girl, who had a left ovarian cystectomy at 4 years old. She presented with left abdominal pain, and abdominal CT scan demonstrated an enlarged ovary measuring 7 cm in size. Emergency laparoscopy revealed a left ovarian torsion and absence of the right ovary, detrosion and pexy of the left ovary were therefore performed. Normal ovary function was confirmed three months after the surgery. Clinical presentation of the normal ovarian torsion was nonspecific and early diagnosis was difficult. Whether the macroscopic appearance is necrotic or not, a detorsed ovary has a high potential for recovery. Torsion of a normal ovary in children should be managed conservatively.

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