Purpose: The operative method of fundoplication for gastroesophageal reflux disease (GERD) is divided into anterior wrapping (AW), such as Dor fundoplication, and posterior wrapping (PW), such as Toupet and Nissen fundoplications. Our institute introduced laparoscopic fundoplication in 2002. AW was performed until 2010, and PW has been performed since 2011. We examined the outcomes of AW and PW.
Methods: We examined 33 cases that we encountered from 2002 to 2013 and compared them retrospectively. The median age was 4 years (0-39 years), 26 patients were boys, and 7 were girls.
Results: Twenty-four patients showed severe motor and intellectual disabilities, six had congenital hiatal hernia, and three showed postoperative esophageal atresia. AW (Dor) was performed in 18 patients, and PW (Nissen fundoplication for 9 patients, Toupet fundoplication for 6 patients) was performed in 15 patients. Compared with AW (p < 0.05), PW is associated with significantly reduced blood loss and operation time. Recurrence was observed in three patients subjected to AW (16.7%) and in 1 patient subjected to PW (6.7%). The recurrence rate was significantly reduced in the PW group. There was no significant difference between Nissen and Toupet fundoplications in terms of recurrence. For the 3 patients who showed recurrence in the AW group, 1 underwent reoperation and 2 were treated conservatively. One patient who underwent Toupet fundoplication showed recurrence.
Conclusions: In our institute, PW was found to be associated with significantly less operation time and intraoperative blood loss than AW. PW is a better procedure than AW for GERD. It was considered important to determine the condition of the patient in the selection of PW as the operative method. In particular, Nissen fundoplication is useful for patients with severe motor and intellectual disabilities.

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Purpose: Rectal prolapse is a relatively common condition in children, with most cases responding to conservative management. A characteristic finding in fluoroscopic contrast enema was observed. We herein report this finding and the difference in this finding between conservative and surgical cases.
Methods: We retrospectively reviewed the cases of 18 patients who had consulted our hospital regarding rectal prolapse between January 2005 and December 2014. The onset, first consultation, symptoms, findings of contrast enema, and results of treatment were obtained from medical records.
Results: The median ages at onset and first consultation were 3.4 and 5.0 years old, respectively. Six patients had constipation, 9 experienced excessive strain upon defecation, and 3 had bloody stools. Eight patients responded to conservative management, whereas 10 patients required surgery. No significant differences were observed in the ages at onset and first consultation, or symptoms between the conservative and surgical cases. We observed that the rectum dropped apart from the sacrum in contrast enema. This finding was defined as insufficient fixation of the rectum. The insufficient fixation spread to the second or third sacrum in the cases treated surgically, but was limited to the first sacrum in those treated conservatively. No recurrent prolapse occurred in both cases treated conservatively and surgically.
Conclusions: Insufficient fixation of the rectum to the sacrum was observed in all the patients, which may affect rectal prolapse. Furthermore, the effectiveness of conservative management appeared to depend on the extent of insufficiency. Rectopexy is an effective procedure because it restores this anatomical disorder.

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Purpose: Although the importance of preoperative colonic decompression for Hirschsprung’s disease (HD) is well recognized, no definitive procedure has yet been established. We herein report our procedure for carrying out the preoperative management of HD.
Methods: Nine patients diagnosed as having HD by contrast enema were managed by preoperative irrigation twice a day and continuous drainage through double transanal tubes made of polyvinyl chloride from January 2010 to May 2015.
Results: There were 2 rectal aganglionosis patients, 5 rectosigmoid aganglionosis patients, 1 long-segment aganglionosis patient, and 1 total colon aganglionosis patient. We fixed the transanal tubes from the sigmoid descending colon junction to the cecum as the extent of the aganglionic segment. The median age at transanal tube fixation was 3 days (range, 1‒130 days), the median length of preoperative tubing was 21 days (range, 17‒88 days), and the median age of primary pull-through was 26 days (range, 20‒301 days). During the tubing period, all patients could be fed by peroral intake. We were able to manage the patient with total colon aganglionosis for 20 days before ileostomy until the diagnosis of HD was confirmed histopathologically, and we successfully performed primary pull-through on the other 8 patients. There were no complications associated with tube insertion, and no worsening of colitis occurred.
Conclusions: We are able to effectively and rapidly perform colonic irrigation with an even intracolonic pressure using our procedure with double transanal tubes. This form of management is therefore considered to be safe and useful for HD patients.

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Purpose: We compared different liver retractors used in laparoscopic fundoplication (LF) and examined how the different choices affected operability, visual field, and postoperative liver function.
Methods: Eleven patients who underwent LF in our department between April 2013 and March 2015 were classified into 3 groups: the N method group (Nathanson liver retractor connected to an Octopus retractor holder, n = 3), the T method group (three-point extension with Teflon tape retraction, n = 5), and the V method group (two-point extension with thread and needle, n = 3). To investigate the difference between the three liver retraction methods, we measured the time required for each liver retraction method and the alanine aminotransferase (ALT) levels preoperatively and on postoperative day (POD) 1 for each method.
Results: The times required for liver retraction were 3.7 min for the N method group, 11.6 min for the T method group, and 10 min for the V method group. The N method group required the shortest time to retract the liver. In all groups, ALT levels on POD 1 significantly increased from preoperative ALT levels, and the V method group showed significantly lower POD 1 and preoperative ALT levels than the N and T method groups. The patients who showed high ALT levels (> 100 IU/l) were younger than those who showed low ALT levels (< 100 IU/l).
Conclusions: It is important to thoroughly understand and consider the merits and demerits of each method when choosing an appropriate method.

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We report the results of two cases requiring emergency surgery after accidental ingestion of magnetic toys. A 17-month-old female (case 1) was brought to a local clinic after ingesting 2 foreign bodies (magnets), and her parents were instructed that she be observed. Thirty hours after the accidental ingestion, she was referred to us. Endoscopic removal of the foreign bodies was attempted, but laparotomy was necessitated owing to impending perforation determined from endoscopic findings. Impending gastric perforation, multiple perforations of the small intestine and perforation of mesenteric membranes were diagnosed and repaired. A 5-year 2-month-old male (case 2) was referred to our department 4 days after accidental ingestion of 9 foreign bodies (magnets), which were radiographically detected. Endoscopic removal was attempted, but laparotomy was performed owing to impending perforation determined from intraoperative findings. Impending gastroduodenal perforation was diagnosed on the basis of laparotomy findings, and then repaired. The courses of patients accidentally ingesting solid foreign bodies, the majority of which would be naturally eliminated, are generally favorable. However, accidental ingestion of foreign bodies can be dangerous in some cases. Multiple magnets accidentally ingested can adhere to each other across the intestinal wall, causing crushing of the intestine and thus intestinal perforation or fistula formation. Individuals who accidentally ingest multiple magnetic materials, even if asymptomatic, may require surgery, and conservative follow-up examination is not recommended in our opinion. Instead, the ingested magnetic materials should be removed as early as possible.

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A 7-year-old boy sometimes had abdominal pain and nausea for the past 2 years. Abdominal ultrasound and video fluoroscopy showed that he had intestinal malrotation. Laparoscopy revealed that the cecum was not fixed to the retroperitoneum and a Ladd’s ligament was found. Moreover, the ligament of Treitz was located medially and abnormally. We diagnosed him as having atypical intestinal malrotation and performed laparoscopic Ladd’s procedure. His appetite was good and he was discharged on postoperative day 7. He had abdominal pain and nausea again on postoperative day 10.Video fluoroscopy showed duodenal stenosis suspected to be related to postoperative adhesions. We performed endoscopic balloon dilatation and the postoperative duodenal stenosis was improved. After that, he no longer had the symptoms.

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Main pancreatic duct injury is rare in children and its therapeutic strategy is still controversial. Here, we report the case of a 6-year-old boy treated by only open drainage without distal pancreatectomy. He presented with abdominal pain after blunt abdominal trauma caused by a handlebar of a bicycle. An imaging study revealed main pancreatic duct injury with a giant pseudocyst, and he was transferred to our hospital 11 days after the onset of the injury. Endoscopic retrograde pancreatography (ERP) was performed, and cannulation into the pseudocyst was unsuccessful. On the day after ERP, he presented with acute abdominal pain with the rupture of the pseudocyst, requiring open drainage. His postoperative course was satisfactory and he was discharged 75 days after the onset with atrophy of the distal pancreas. Conservative management of pancreatic duct injury in children with or without drainage is associated with an extended hospital stay duration and the prolonged need for TPN. Operative management with pancreatic surgery could shorten the hospital stay but with the risk of surgical complications. Therefore, the choice of therapeutic strategy should depend on the patient’s condition.

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We report the case of a pediatric patient with isolated esophageal atresia (EA) and foregut-derived cysts (FCs). At 24 weeks of gestation, sonographic examination revealed EA and an intrathoracic cyst. The male baby weighing 1,726 g was born at 36 weeks of gestation and was diagnosed as having EA associated with a mediastinal cyst. During his early postnatal life, he developed transient respiratory impairment. After 20 attempts of mechanical bougienage of both the upper and lower esophageal pouches, he underwent cystectomy and esophagoesophagostomy concomitantly at 192 days of age. Histopathological examination revealed the cyst wall to be lined with ciliated columnar and squamous epithelial cells, confirming the diagnosis of FC. In most neonates with isolated EA, end-to-end esophagoesophagostomy requires time for completion because of the long distance between the upper and lower esophageal segments. FC commonly occurs in the posterior mediastinum, and occasional cyst enlargement causes respiratory dysfunction and negatively impacts the standard therapeutic strategy for EA. During the stand-by for concomitant surgery for EA and FC, we should simulate emergent respiratory depression and formulate a strategy beforehand to cope with it.

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The infant stool color card screening system (CCSS) is used to confirm stool color in order to increase the rate of early diagnosis of biliary atresia (BA). In 2012, a nationwide stool CCSS was introduced in Japan. Here, we report the cases of three infants with BA, who could not be diagnosed using the stool CCSS. The infants underwent surgery at approximately 3 months of age. Each infant initially had yellowish stools that became pale yellow or whitish. Mothers and caregivers should be made aware that infants with BA usually pass yellowish stools in the early neonatal period, which may become pale yellow or whitish later. Mothers, physicians, and public health nurses tend to be unaware of BA owing to normalcy bias, which is a major problem. The following measures are important in order to diagnose BA using a stool color card and improve the prognosis of infants with BA: (1) mothers should check the stool color of infants regularly; (2) information should be unified and consistently provided to pediatric surgeons, pediatricians, and public health nurses; and (3) the healthcare system should be reformed and made more convenient to avoid overlooking BA. Measuring bilirubin and urinary sulfated bile acid levels and obtaining images of stools are useful and cost-effective methods to screen for BA.

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Traumatic impalement anorectal injury in a child is rare and often associated with injuries to the pelvic and abdominal viscera. We report the case of a patient with impalement injury to the rectum. A 7-year-old boy suffered accidental trauma to the anus from an S-shaped metal hook hanging on a column when he jumped over a fence in a garden. After removing it himself, he was immediately brought to a regional hospital with anal pain and bleeding. Anorectal injury was suspected and he was transferred to our hospital. Penetrating rectal injury to the posterior side was diagnosed on the basis of proctoscopy findings. Abdominal computed tomography showed free air in the pararectal space of the pelvic cavity, but no evidence of intra-abdominal free air or urinary tract injury. The perforation of the posterior wall of the rectum including the internal anal sphincter was closed by primary suturing without colostomy. The postoperative course was uneventful and the patient was discharged on postoperative day 7. Impalement injury to the rectum has been reported for 64 children in Japan. Cases involving patients treated by primary repair without colostomy for pediatric transanal impalement injury are rare. According to the degree of perineal and anorectal impalement injuries, primary repair without colostomy may be an option and may lead to a good prognosis.

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