Purpose: The Nuss procedure became a standard operation procedure for pectus excavatum. However, the optimal age for this operation has not been identified. Hence, in order to determine any long-term changes in the chest of older children, we measured the vertebral index (VI) in patients who underwent bar removal and followed up the patients for 3 years.

Methods: We reviewed the cases of 18 patients (13 boys and 5 girls) whose bar was removed between 10 and 14 years of age. They were followed up for three years after the bar removal. The mean age at primary surgery was 8.3 ± 1.2 (range: 5–10); at removal, the mean age was 11 ± 0.7 (range: 10–12), and the mean period between the initial operation and the bar removal was 30.7 ± 10.7 months. VI was measured from a lateral chest X-ray at 5 time points: before the Nuss procedure, immediately after bar removal, and one year, two years, and three years after bar removal.

Results: The VIs were as follows: before the Nuss procedure, 31.7 ± 7.9; immediately after removal, 23.7 ± 2.9; one year after removal, 23.9 ± 3.2; two years after removal, 25.2 ± 3.8; three years after removal, 24.8 ± 2.9. No statistical difference in VI was observed among the three groups.

Conclusion: In the cases of bar removal between the ages of 10 and 14, there was no evidence of long-term VI change. This means that the recurrence of pectus excavatum is less likely in these cases. It can be proposed that the optimal age for the Nuss procedure is 8 years or higher.

Purpose: The purpose of this study is to review the postoperative course of female patients with low-type anorectal malformations reoperated by limited posterior sagittal anorectoplasty (PSARP) for cosmetic reasons, who were treated by cutback anoplasty previously.

Methods: Fifteen patients were categorized into three groups (before 1 y.o., 1–5 y.o., and over 6 y.o.), and the postoperative lengths of stay (LOS), complications, and anorectal functions were compared between the groups.

Results: There were no obvious differences with increasing LOS and in terms of complications as the patients aged.

Conclusions: Surgeons should not hesitate for fear of complications in providing reanoplasty for cosmetic reasons by PSARP to patients of all the ages from infancy to school age.

Purpose: Over 75% of patients with pediatric idiopathic intussusception can be treated using high-pressure enema. However, recurrence occurs in some cases. Ileocecal lymphoid tissues play a role in the onset, but the cause of recurrence remains unclear.

Methods: We measured the wall thickness of the terminal ileum (WTTI) using ultrasound after treatment of cases of recurrent and nonrecurrent pediatric idiopathic intussusception. We included 27 patients (recurrent group, 4 patients; nonrecurrent group, 23 patients). For both groups, we considered background factors (sex, prior infection, age, body temperature, WBC count, and CRP level). We performed regression analysis to examine whether WTTI after reduction was associated with recurrence.

Results: There were no significant differences in the background factors between the groups. WTTI in the nonrecurrent group decreased rapidly. Using regression analysis, the elapsed time until 2 mm reduction was found to be 55 hours.

On the other hand, WTTI in the recurrent group decreased gradually and seemed to remain constant at 6.5 mm. There was a significant difference in the average WTTI between both groups 24 hours after reduction.

Conclusions: We found that sustained intestinal wall thickness after reduction was a factor associated with the recurrence of this disease. It is possible to predict the risk of recurrence by evaluating the trend of decrease in WTTI after reduction.

Purpose: We reviewed our experience in treating patients with biliary atresia (BA) associated with vitamin K deficiency bleeding (VKDB) in a single institution to assess their outcomes.

Methods: A retrospective study of 76 patients who underwent a Kasai operation from 1981 to 2016 was carried out. The patients were divided into two groups: group A (n = 9) consisted of patients who showed BA with VKDB, and group B (n = 67) consisted of patients who showed BA without VKDB. The characteristics, clinical parameters, disappearance rates of jaundice and cumulative native liver survival rate were retrospectively assessed. Furthermore, the characteristics of the patients in group A were assessed in detail.

Results: There was no statistically significant difference in the characteristics and clinical parameters between the two groups. The age at the time of Kasai operation was significantly higher and the disappearance rate of jaundice was significantly lower in group A than in group B. Furthermore, the overall 10-year cumulative native liver survival rate was significantly lower in group A than in group B (p < 0.05). Eight of the nine patients in group A were fed with breast milk. The ages at onset of VKDB ranged from 41 to 84 days. Four of these nine group A patients had intracranial hemorrhage. They had no neurological sequelae.

Conclusion: In the patients with BA associated with VKDB, the age at the time of Kasai operation was delayed. These patients tended to have intracranial hemorrhage as a complication and had a poor prognosis. The early detection of BA is essential for preventing VKDB and intracranial hemorrhage.

Rhabdomyosarcoma (RMS), a soft tissue sarcoma, is one of the most common pediatric cancers. Although it normally arises within the head and neck regions and the genitourinary system, primary RMS of the ovary is extremely rare. In this report, we present the case of a 9-year-old patient with an embryonal RMS arising in the left ovary. She complained of progressive abdominal pain and constipation for the past 2 months. As the pain rapidly progressed, causing anorexia, she was brought to our hospital. Physical examination revealed a lower quadrant abdominal mass. Computed tomography showed a large heterogenous pelvic mass and some ascetic fluid. Tumor biopsy was performed and histopathological analysis indicated embryonal RMS. She received chemotherapy including vincristine, doxorubicin, cyclophosphamide, ifosfamide, and cisplatin with good response to the chemotherapy. After 7 months of hospitalization, surgical resection was performed, and a mass in the left ovary was discovered. Her primary tumor was completely resected, and she received postoperative chemotherapy. No recurrence of the disease was seen in a follow-up period of approximately 45 months at the time of writing this report.

We present the case of a 8-year-old child who presented with traumatic right testicular dislocation resulting from a blunt scrotal injury. He had been kicked, which did not involve his left testis in his left scrotum. He was admitted to our hospital with the complaint of right inguinal pain and dilation. The right testis was dislocated at the right inguinal region. Inguinal exploration confirmed an ischemic testis, which was relocated out of the scrotum and an orchiotomy was performed. This case emphasized that surgical exploration must be performed without hesitation on patients suspected of having ischemic testis.

We report the case of a male infant in whom fetal hydrocephalus and abdominal distention were detected. The infant was diagnosed as having X-linked hydrocephalus (XLH) on the basis of gender, physical findings and a mutation of L1CAM. Ventriculoperitoneal shunting for congenital hydrocephalus was performed. Abdominal distention was becoming worse, so we suspected Hirschsprung’s disease (HD) as a complication with L1CAM mutation. On the basis of enema examination, anorectal pressure study and rectal biopsy findings, the patient was diagnosed as having HD. The abdominal symptoms were improved by the Soave pull-through method. L1CAM mutations cause several disorders such as hydrocephalus, and some cases complicated by HD have been reported in the literature. The possibility of HD should be a concern when we examine congenital hydrocephalus patients with abdominal distention or obstinate constipation.

We report a rare case of tubular duplication of the terminal ileum and the entire colon with a rectovaginal fistula and a normal anus in a female patient. She was suspected of having duplication of the urinary bladder prenatally. After birth, we diagnosed her as having a rectovestibular fistula with a normal anus and performed colostomy. During the operation, we encountered tubular duplication of the terminal ileum and the entire colon, complicated by duplicated urethra, vagina and uterus. When the patient was six months of age, we performed closure of the rectovaginal fistula and side-to-side anastomosis of the duplicated rectum, but the rectovaginal fistula recurred postoperatively. When the patient was eight months of age, we carried out reclosure of the fistula and performed resection of the duplicated ileum and ascending colon, partial resection of the septum, and stoma closure two months later. Her postoperative course was uneventful.

Ramstedt’s pyloromyotomy is generally useful for the successful release of gastric obstruction in most cases of infantile hypertrophic pyloric stenosis (HPS). However, in rare cases, repyloromyotomy is necessary to treat postoperative remnant pyloric stenosis. Repyloromyotomy by the same method as the first pyloromyotomy using the popular Tan-Bianchi (TB) method is risky owing to scarring or adhesion of the operating field. The umbilical sliding window (USW) method for repyloromyotomy reduces the risk of intra-abdominal injury associated with reoperation. A 7-month-old boy after pyloromyotomy using the TB method suffered from prolonged nonbilious vomiting. An upper gastrointestinal examination showed difficulty in passage of the contrast medium through the pylorus, and ultrasonography revealed a hypertrophic pyloric muscular layer. We performed repyloromyotomy using the USW method to treat his remnant pyloric stenosis. His postoperative course was uneventful with a good outcome cosmetically.

A 7-year-old boy with asphyxia and chronic renal failure was referred to our department with melena and intense anemia. We were unable to identify the bleeding source by upper gastrointestinal endoscopy, colonoscopy, or ^99mTc-pertechnetate scintigraphy. Capsule endoscopy revealed a bleeding point in the upper part of the jejunum, and enteroscopy showed a 3-mm-diameter mass oozing with blood. He underwent enteroscopic clipping for the bleeding source, but melena persisted. Six days after clipping, we performed abdominal surgery. During laparotomy, we palpated the clip in the jejunum 3 cm from the Treitz ligament. Intraoperative enteroscopy showed that the clip was still in place on the mass, and we performed wedge resection of the jejunum, including the clip. The postoperative course was uneventful, and the patient was discharged on the 26th postoperative day. The final histopathological diagnosis was heterotopic Brunner’s gland of the small intestine. Although this disease is extremely rare, it must be included in the differential diagnosis of intestinal bleeding.

Double common bile duct is an extremely rare anomaly, in which 2 common bile ducts exist. We encountered a case of a 2-year-old girl with double common bile duct associated with pancreaticobiliary maljunction, which was diagnosed preoperatively. Firstly, she complained of abdominal pain with vomiting and presented with hyperamylasemia. She was transferred to our hospital with the diagnosis of choledochal cyst. MRCP and DIC-CT revealed double common bile duct associated with atypical pancreaticobiliary maljunction. Intraoperative cholangiography was carried out to confirm the details of the anatomy of the extrahepatic bile duct. The accessory common bile duct branched from the right hepatic duct and joined the main pancreatic duct. We performed a diversion surgery via resection of the extrahepatic bile duct, including the accessory common bile duct. The postoperative course was satisfactory. Careful preoperative imaging tests enabled safe operation with an appropriate margin for extrahepatic bile duct resection.

A 6-year-old girl presented to our hospital with symptoms of rectal prolapse. She reported urinary disturbance over the last few years, which had continued until the time of her visit to our hospital. She reported regular defecation, and a digital examination showed no fecalith or mass. Abdominal X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) revealed a 4.5 cm calcified mass in her bladder; therefore, she was diagnosed as having a bladder stone. An emergency lithotomy was performed owing to uncontrollable pain. Her bladder was opened and the stone was removed. Analysis of the calculus and urinary amino acid analysis revealed the presence of cystinuria. Her rectal prolapse and dysuria disappeared after the treatment. It is rare to encounter a patient having bladder stones and concomitant rectal prolapse. We propose that bladder stones cause dysuria and the elevation of abdominal pressure due to straining. At the same time, bladder stones stimulate pelvic nerves, which cause hyperperistalsis of the bladder, relaxation of anal sphincter muscles, and rectal prolapse. In cases of rectal prolapse without constipation, it is important to determine the cause of dysuria.

Internal herniation through the foramen of Winslow (HFW) is extremely rare and is commonly diagnosed at the time of surgery, as clinical findings are nonspecific. There has been no written report about a laparoscopic approach to HFW in a pediatric population, although several reports have recently addressed the usefulness of such an approach in adults. We report the case of a 13-year-old female patient who was preoperatively diagnosed as having HFW on the basis of computed tomography (CT) findings and who successfully underwent laparoscopic repair of HFW. The child was referred to our hospital after presenting to a different clinic with sudden-onset upper-right abdominal pain. We diagnosed her as having HFW because a CT scan with intravenous contrast showed a distended small intestine protruding into the omental bursa through the foramen of Winslow. An urgent laparoscopic exploration was performed approximately 12 hours after the onset of symptoms. Reduction of the herniated bowel was achieved laparoscopically with gentle traction. The reduced intestine appeared viable, so no resection was needed. At the end of surgery, the hernial defect obliterated. The patient recovered well with an uneventful postoperative course and was discharged. Prompt diagnosis and early exploration may lead to less invasive management of HFW.

We report a case of inguinal bladder hernia in an infant. A 143-day-old boy was referred to us with irreducible left groin bulging. Ultrasonography revealed herniation of a part of the bladder wall from the pelvis to the left inguinal canal. Retrograde cystourethrography showed left inguinal bladder herniation. He developed right inguinal hernia of the intestine at the same time. We performed only right inguinal herniorrhaphy by the Mitchell Banks technique. We followed-up the patient, expecting spontaneous resolution of the left inguinal bladder hernia. After the operation, his left groin bulging improved. Bladder inguinal hernia in an infant includes the risk of intraoperative bladder injury. We considered that it was possible to withhold operation and to only follow up such a case with accurate diagnosis.

Living donor liver transplantation (LTx) for hepatoblastoma (HB) involving the inferior vena cava (IVC) is still challenging, because it may require veno-venous bypass (vvbp) utilizing extracorporeal circulation and vascular reconstruction. We herein report three cases of HB involving the IVC and discuss our surgical strategies. Case 1 is an 18-month-old boy diagnosed as having POSTEXT IV HB, which extended to the right atrium and the suprahepatic IVC. A living donor LTx was performed utilizing vvbp, and an autopericardial patch graft was used for the reconstruction of the IVC. Case 2 is a 7-month-old boy who presented with POSTEXT IV HB, which obstructed the IVC completely. Blood from the lower part of the body returned to the right atrium through the intrahepatic shunt. The IVC was replaced with a superficial femoral vein from a donor at the time of LTx. Case 3 is an 8-month-old boy diagnosed as having POSTEXT II HB, which involved the IVC, and who underwent LTx. Vvbp was utilized at the time of hepatectomy to avoid the rupture of the tumor. All three patients have been recurrence-free for 16–33 months since the LTx.

An otherwise healthy two-year-old boy was referred to our department with intermittent mucous drainage from the fistula in the middle of the inside margin of the sternocleidomastoid muscle after birth. Fistulography revealed that the fistula was branched and limited to the submandibular triangle. This tract originated from the normal left submandibular gland. The lesion was explored surgically by spindle incision surrounding the orifice and the fistula was dissected up to the submandibular gland. Wharton’s duct was opened normally at the sublingual caruncle. The postoperative course was uneventful. Histological examination revealed a sero-mucinous salivary gland with the ducts lined by stratified squamous epithelium consistent with congenital salivary fistula.

Right inguinal hernia containing the uterus and bilateral adnexa in a female infant is very rare (0.3% of all famale inguinal hemia). In a girl aged 1 year and 1 month, right inguinal hernia was found at 1 month of age. We confirmed the hernia contents by a preoperative ultrasonic examination. However, from palpation immediately before the operation, we determined that we had to be extra careful during surgery. We performed the Potts method. As a mechanism of the occurrence of this disease, (1) when the appendage escapes, the uterus interlaminar membrane is pulled and the uterine contralateral ovary escapes. The other factors are as follows: (2) vulnerability of the anchoring ligament in the uterus and ovary, (3) excessive abdominal pressure, and (4) enlargement of the inner inguinal ring. As a cause of inguinal hernia, there are reports on conditions accompanying true hermaphrodism and a monocular uterus. Herniated contents should be confirmed accurately by direct visual observation, as in our patient, or laparoscopic observation.

Omental torsion is a rare cause of acute abdomen in children. We present a case report of an 11-year-old girl who was diagnosed as having omental torsion with ileal volvulus. She complained of acute abdominal pain and nausea that started 2–3 hours before arrival. She experiences a similar abdominal pain with vomiting that recurs once a month since 1 year earlier. Each episode continued for 3–5 hours and disappeared spontaneously. The abdominal wall was soft and flat, and there was tenderness in the lower abdomen. Contrast-enhanced abdominal CT imaging revealed a whirl sign of the mesenteric artery and caliber change of the terminal ileum. A high-density mass with helical strands of the omentum was identified retrospectively. An emergency operation was performed under a provisional diagnosis of ileal volvulus. During diagnostic laparoscopy, omental torsion due to adhesion to the ileum was observed, whereas the ileal volvulus was released spontaneously. Neither ileum nor omentum showed necrosis. Resection of adhesion was performed. It was considered that recurrent ileal volvulus gradually caused the omental torsion.