Purpose: Intestinal duplication cysts are usually excised while including the adjacent normal intestine. However, if the lesion is located in the ileocecum, preservation of the ileocecal valve (ICV) should be considered. We evaluated the validity of mucosectomy of the ileocecal duplication cyst from the perspective of preserving ICV.
Methods: Between 1995 and 2011, 9 consecutive patients with duplication cysts located in the small intestine or ileocecum were surgically treated in our institution. The mucosectomy (group I) was performed in 6 patients (ileocecum: n = 3, ileum: n = 3), and total excision (group II) was performed in 3 patients (ileocecum: n = 2, ileum: n = 1). Mean operative time (OT), intraoperative blood loss (BL), and postoperative resumption of oral intake (OI) were compared between the 2 groups.
Results: OT, BL, and OI in groups 1 and 2 were 127 and 145 min, 42 and 27.3 ml, and 4.0 and 5.3 days, respectively. We have had no complication or recurrence for a mean follow-up period of 7.3 years except for one patient who developed diarrhea after ICV resection in group 2, which resolved within one month.
Conclusion: The presented results showed that mucosectomy was not inferior to the conventional en bloc excision. Therefore, mucosectomy for ileocecal duplication cyst would be a considerable therapeutic option to preserve the ICV.

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Purpose: There are many reports on the prenatal severity index, which is a measure of the lung capacity of fetuses with congenital diaphragmatic hernia (CDH). However, whether this index can serve as a true measure for evaluating cardiopulmonary hypoplasia remains controversial. We devised an index for measuring the severity of prenatal CDH by fetal cardiac ultrasonography and for evaluating the prognosis.
Methods: Since 1997, we have performed 57 fetal cardiac ultrasonography procedures on 27 fetuses with left isolated CDH at our institution. These 27 fetuses did not have any other malformations. Ninety-nine fetuses without cardiac or lung disease served as the control group. We examined the outcomes on the basis of the tricuspid valve-to-mitral valve diameter ratio (TV/MV ratio), pulmonary valve-to-aortic valve diameter ratio (PV/AV ratio), and cardiothoracic area ratio (CTAR). Next, we compared the survival group (SG) with the nonsurvival group (NSG) and retrospectively examined the blood flow direction of the ductus arteriosus using clinical data.
Results: CTAR, PV/AV ratio, and TV/MV ratio were significantly different between the control group and the CDH group. CTAR was significantly different between SG and NSG (p = 0.01), whereas PV/AV ratio was not significantly differently between these groups. TV/MV ratio was significantly different between NSG and SG (p < 0.001). For patients of advanced gestational age, TV/MV ratio increased in NSG. CTAR and PV/AV ratio were not significantly different in relation to the blood flow direction of the ductus arteriosus, whereas TV/MV ratio was significantly different between NSG and SG.
Conclusion: Fetal cardiac ultrasonography is valuable for prenatal diagnosis of CDH. In particular, TV/MV ratio reflected severity 32 weeks later and is thus useful as a prenatal severity index.

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Purpose: In patients with trisomy 18, performing radical operation for esophageal atresia with trachea-esophageal fistula (EA + TEF) is controversial. We reviewed our cases and evaluated the surgical outcomes of these patients in terms of the possibility of enteral feeding.
Methods: Thirteen trisomy 18 patients were encountered in this study. All the patients underwent gastrostomy. The patients were divided into four groups according to the additional operation aside from gastrostomy, namely, group 1: esophago-esophagostomy with TEF division as a radical operation (n = 6), group 2: TEF division only (n = 2), group 3: esophageal banding (n = 1), and group 4: no additional operation (n = 4).
Results: All the patients who underwent additional procedures (groups 1, 2, and 3) could start enteral feeding except one patient in group 1 (duration of feeding, 4 to 1,768 days). Only one of four patients could start enteral feeding via gastrostomy for two days in group 4.
Conclusion: To feed trisomy 18 patients with EA + TEF, an additional operation, aside from gastrostomy, is mandatory.

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There are few long-term survivors of chronic idiopathic intestinal pseudo-obstruction (CIIP). Here, we report the case of a 20-year-old man with CIIP. He was born after 37 weeks of gestation and was hospitalized in the neonatal intensive care unit (NICU) owing to low birth weight. His bowel condition was normal at first; however, he developed strangulation ileus at two months of age and underwent partial resection of the intestine following ileostomy. After the stoma closure, he started to exhibit the episode that repeat ileus symptoms. He was referred to our hospital at the age of nine, and he has been receiving nutrition parenterally. The excretion of bowel contents from the ileal stoma was insufficient, and bowel decompression using a long tube was also unsuccessful. At the age of 14, the right side of the colon and a major part of the small intestine were removed, leaving 70 cm of the oral jejunum; then, side-to-side jejunocolostomy with end-jejunostomy was performed. After the operation, his general condition improved markedly with efficient drainage from the ileus tube and jejunostomy. From our limited experience, shortening of the intestine might be an effective surgical strategy in CIIP patients for the adequate drainage of intestinal content and the prevention of TPN-related complications.

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A 9-year-old girl presented with a right supraclavicular mass that had persisted for a month. She visited a clinic because the mass started to increase in size. An US evaluation revealed a 35 mm cystic mass with blood flow in the right supraclavicular region. She was referred to our hospital for further investigation. The blood flow was confirmed in the mass by dynamic CT. We suspected a venous aneurysm (VA) because the contrast enhancement in the mass was poor in the arterial phase on the obtained dynamic CT images. We resected the VA because the patient complained of pain in the right supraclavicular region. Intraoperatively, the mass was found to be 50 × 35 mm in size, connected to the right external jugular vein, and to contain a thrombus. We diagnosed the mass as VA. Following surgery, the patient has remained asymptomatic for more than one year. VA is a rare disease, especially in children, and different from varix. VAs in the head and neck regions are typically asymptomatic. However, we recommend resection if possible for VA patients, especially symptomatic patients, such as our present patient.

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A 14-year-old boy had suffered from abdominal pain, vomiting, and diarrhea. We diagnosed him as having gastroenteritis at first, but high-grade fever and elevation of white blood cell counts lasted for 5 days. Abdominal pain became worse. Hydrothorax and ascites appeared. Antibiotics were not effective. From clinical findings and computed tomography, a strangulated ileus was suspected. A laparotomy was performed 5 days after admission, which revealed that almost the entire small intestine was edematous and inflammatory. In particular, the terminal ileum was swollen and red. We performed biopsy of the terminal ileum and swollen mesenteric lymph node. Pathological diagnosis revealed histiocytic necrotizing lymphadenitis (HNL). His symptoms and laboratory data significantly improved after the operation. He was discharged after 13 days of hospitalization. We experienced a case of HNL-associated mesentery in a child. As differential diagnosis, we must consider strangulated ileus as the disease.

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The management strategy for pediatric traumatic pancreatic injury, which involves the laceration of the main pancreatic duct, has never been standardized. We report herein two cases of complete traumatic pancreatic transection in patients who underwent percutaneous transgastric drainage tube placement. The patients were a 14-year-old boy and a 7-year-old boy. They were admitted to our hospital with type IIIb pancreatic injury (Japanese Association for the Surgery of Trauma). Because the initial conservative therapies were ineffective, a percutaneous transgastric stent tube was placed between the stomach and the transected pancreas stump to drain the pancreatic juice into the stomach and to preserve the distal part of the transected pancreas. In both patients, although the transient drainage was effective and the symptoms promptly resolved without any complications, an internal fistula did not form, resulting in the atrophy of the distal pancreas. In conclusion, transgastric stent tube placement is effective for transient drainage, but further improvement is required for permanent internal fistulization.

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Volvulus of the transverse colon is very rare and often develops in patients with mental and physiological growth retardation. We report the case of a 17-year-old boy who developed volvulus of the transverse colon; this patient has X-linked mental retardation with alpha-thalassemia (ATR-X syndrome), diagnosed when he was 3 years old. He was admitted to our hospital because of abdominal distention and vomiting. Abdominal radiography and CT revealed markedly dilated intestines, and the diagnosis of volvulus of the transverse colon was made. Reduction of the torsion was attempted through a transanal long tube but was not successful. Therefore, we performed an emergent surgical detorsion. During the operation, volvulus of the long dilated transverse colon was found and the twisted colon underwent infarction. After the detorsion, resection of the necrotic colon and end-colostomy were performed. His postoperative course was uneventful and he started oral intake on postoperative day 15. No recurrence was found for 6 months later and his bowel habits gradually improved. Early detection and diagnosis of acute abdomen in patients with mental and physiological retardation are difficult. Volvulus of the transverse colon should be considered in cases of acute abdomen developed in such patients.

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A 2-day-old girl, who was born at full term with a weight of 3,260 g, presented with abdominal distension and continuous vomiting. An abdominal roentgenogram showed multiple distensions of the small intestinal loop and a soap-bubble appearance in the lower abdomen. The followingcontrast enema using gastrografin revealed a distal microcolonand a colonic obstruction near the cecum. In the region of the obstruction, the contrast collected in the pouch formed by the membrane, which distended into the dilated cecum. When the contrast was deflated, the wind-sock-like membrane was reversed in the opposite direction by the pressure of the cecal contents. A diagnosis of membranous atresia of the ascending colon was made, and the patientunderwent surgery. To avoid an ileocecal resection, a resection of the membrane and a tube cecostomy were performed with an indwelt transanastomotic tube. After the operation, so as not to have a stagnant loop, the patient was fed orally with careful observation, and the cecum was deflated through the cecostomy for 2 months. The cecostomy functioned subsequently as a safety valve and was closed 11 months after the initial operation. The patient is doing well at age 4 with normal ileocecal valve function and within a normal growth range. Although membranous atresia of the colon is a rare cause of intestinal obstruction in neonates, the “reversed wind sock sign” that we described for the first time in the literature is notable in making a definitive preoperative diagnosis of such atresia.

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A newborn or infant with fenestrated duodenal web generally presents with vomiting. Children or older patients with this condition also present with duodenal obstructive symptoms. We herein report a case of duodenal web in a child presenting with not obstruction but recurrent pancreatitis. A 2.9-year-old boy with a 6-month history of recurrent back pain was referred to our hospital. An ultrasound examination revealed intraluminal fluid collection and entire wall thickening in the second portion of the duodenum. An upper gastrointestinal series revealed a ‘wind sock’ web in the duodenum. Under the diagnosis of membranous duodenal stenosis, the duodenal web was safely and reliably resected laparoscopically with the aid of preoperative endoscopic marking on the duodenal wall on the opposite side of the papilla and placement of an enteric tube through the web.

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Most umbilical hernias disappear spontaneously by 2 years of age. However, patients who have had a giant umbilical hernia (≧20 mm diameter) in infancy sometimes suffer from an ugly umbilicus with extra large skin even after the spontaneous closure of the umbilical hernia. We present 4 cases of giant umbilical hernia operated in early infancy to discuss the timing of early surgical closure. Operations were performed at the time of laparoscopic inguinal hernia repair in 4 female infants from 2012 to 2014. The preoperative circumferences of the umbilicus were 30, 28, 27, and 22 mm. All the patients had a very beautiful umbilicus with a markedly smaller circumference (12–15 mm) 1 month after operation. Early operative repair of umbilical hernia in infancy leads to a reduced circumference of the umbilicus and a beautiful outcome.

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A 1-year-old female was treated for a right inguinal hernia by the Mitchell-Banks procedure. On the 8th postoperative day, she appeared with a 20-mm-diameter mass indicated by ultrasound in the right inguinal region. Because recurrence of a right inguinal hernia with incarceration of the right fallopian tube could not be ruled out, reoperation was performed. The exploratory inguinal incision revealed a hematoma of the round ligament of the uterus. A laparoscopic examination revealed that the bilateral ovaries were intact and the right fallopian tube was caught in the internal inguinal ring. After peeling the tube off from the right internal inguinal ring, the remaining patent processus vaginalis was closed laparoscopically with a purse-string suture. Even the Mitchell-Banks procedure, where herniorrhaphy is performed without opening the inguinal canal, is associated with a risk of fallopian tubal occlusion. Pediatric surgeons need to keep in mind that risk when performing herniorrhaphy in female infants.

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We have experienced treating a rare case of lymphangioma that occurred in the inguinal canal continuous to the retroperitoneal space through the internal inguinal ring. The patient was a 5-year-old female who developed a right groin bulge. She was referred to our institution with suspicion of right inguinal hernia. Imaging studies demonstrated a multicystic tumor in the inguinal canal continuous to the abdominal cavity through the internal inguinal ring. These findings led to a diagnosis of lymphangioma and an operation was performed with laparoscopic assistance. The retroperitoneal cystic mass was attached to the round ligament of the uterus and it was slipping into the inguinal canal with the retraction of the inguinal lesion. We performed en bloc excision of the connected tumor from the inguinal canal. The histopathological analysis of the excised tumor confirmed the diagnosis of lymphangioma, which requires a complete resection to prevent relapse. Regarding the decision to perform complete resection, accurate diagnosis and operation assisted by laparoscopy are useful in such a case.

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