Purpose: Primary spontaneous pneumothorax (PSP) is relatively rare in children. The aim of this retrospective study was to review the clinical features of PSP and devise strategies for its appropriate treatment.
Methods: The medical records of all children aged 15 years and younger diagnosed with PSP between April 2006 and December 2011 were reviewed. We analyzed the records and extracted multiple medical parameters.
Results: Seven children (six boys and one girl; mean age of 14 years and 7 months) with PSP were found. Six of the seven patients were 15 years old. Four of the seven patients were initially treated with chest-tube drainage, and two had persistent air leak until surgery. All patients had an ectomorphic body type with no relevant past medical/family history. Computed tomography revealed definite multiple bullous lesions at the lung apex in all patients, and all underwent a surgical procedure (video-assisted thoracic surgery, VATS) at the initial presentation. Wedge resection (“bullectomy”) with pleurodesis was performed in all patients. No patient showed recurrent ipsilateral pneumothorax but four developed delayed contralateral PSP. Compared with adult patients with PSP treated in our hospital, the pediatric patients presented a more contralateral PSP after surgery (p＝0.0002).
Conclusions: We observed similar trends in gender predisposition and body habitus between children and adults with PSP. VATS was useful in pediatric cases. The risk of contralateral PSP after surgery was greater in children than in adults; therefore, careful follow-up is necessary.
Purpose: Undescended testis (UDT) is commonly associated with gastroschisis. It is considered that the reduction in abdominal pressure during the fetal period leads to the occurrence of UDT. However, the actual cause of UDT is unknown. We report on the association between undescended testis and gastroschisis.
Methods: We reviewed the cases of 13 male neonates with gastroschisis, who were born at our institution from 2006 to 2015. They were classified into two groups: the undescended testis (UDT) group and the normal (N) group (i.e., descended testis). We examined their gestational age, birth weight, defect diameter, number of days until abdominal wall closure after siloplasty, position of the testis, and the course of UDT.
Results: We performed siloplasty in all of the 13 neonates. Six neonates had UDT (46.2%). All neonates had unilateral UDT. There were no significant differences in background factors such as gestational age, birth weight, and defect diameter between the UDT group and the N group. However, the time until abdominal wall closure after siloplasty was significantly longer in the UDT group than in the N group (9.8 vs 6 days, P = 0.011). In addition, we observed UDT complicated by gastroschisis until one year of age similarly to general UDT. Natural descent of the testes occurred in only one patient (16.7%).
Conclusions: There is a tendency that the time until abdominal wall closure after siloplasty becomes longer if gastroschisis is present with UDT than without UDT. It is suggested that the decrease in intraperitoneal pressure during the fetal period may cause insufficient capacity for development of the abdominal wall and cause UDT. UDT complicated by gastroschisis should be treated by elective surgery. However, the natural descent of the testis has a lower tendency in UDT complicated by gastroschisis than in general UDT. Therefore, the possibility that surgery is required is high.
Purpose: While the classical type of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome includes uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis, a recent series reveals several new types. The purpose of this study was to clarify the clinical features of OHVIRA syndrome in our institution.
Methods: All patients with OHVIRA syndrome were identified from 2003 to 2015 except for patients with anorectal malformation. The clinical and radiological findings were retrospectively reviewed. We also identified all female patients with renal agenesis in the same periods to estimate the frequency of OHVIRA syndrome among them.
Results: Nine patients were identified. Five patients had right side obstruction and four had left side. Three patients presented with abdominal pain during puberty. Four patients were detected by prenatal ultrasonography. One two-year-old patient was accidentally found by an imaging study of another disease. One patient was found during follow up of single kidney with vesicoureteral reflux. Four patients underwent vaginoplasty at the ages of fourteen, twelve, eleven, and six. One patient had spontaneous rupture of the obstructed hemivagina immediately after birth. Four asymptomatic patients were managed conservatively. Seven patients had renal agenesis and two patients had hypo/dysplastic kidney with ectopic ureter. Among the fifty patients with unilateral renal agenesis identified by an imaging study in the same periods, eight patients (53.3%) were diagnosed as having OHVIRA syndrome.
Conclusions: It is important to be aware of OHVIRA syndrome not only in patients with renal agenesis but also hypo/dysplastic kidney or multicystic dysplastic kidney (MCDK).
Purpose: Recently, Laparoscopic percutaneous extraperitoneal closure (LPEC) has been selected for hernia patients in many institutions. In our department, this technique has been adopted as a standard technique for pediatric inguinal hernia (IH) since 2007. The aim of this study is to evaluate the advantages of LPEC by comparing it with Potts’ procedure.
Methods: The subjects were 792 patients who underwent surgery for pediatric IH in our department between 2002 and 2015. Of these, 400 who underwent LPEC, which was introduced in June 2007, were assigned to Group L, and 392 who underwent Potts’ procedure were assigned to Group P. The clinical records were compared between the two groups.
Results: Among patients with unilateral hernia, the mean durations of surgery in Groups L and P were 45.8 and 41.4 min, respectively, showing a significant difference. On the other hand, among those with bilateral hernia, they were 54.8 and 83.2 min, respectively; it was significantly shorter in Group L. In 125 of 362 patients diagnosed with unilateral IH before surgery in Group L, the intraoperative findings suggested CPPV. The onset of contralateral hernia was detected in 1.7% with unilateral hernia in Group L and in 10.4% with unilateral hernia in Group P. In Group L, the incidence of postoperative contralateral hernia was significantly lower. The recurrence rates were similar between the two groups.
Conclusions: LPEC may shorten the duration of surgery for bilateral IH and reduce the incidence of postoperative contralateral hernia, with a low incidence of intra-/postoperative complications. Therefore, LPEC may be highly safe and useful.
A female neonate presented with inspiratory stridor and a persistent respiratory disorder after birth. Endotracheal intubation was performed because laryngoscopy revealed a mass lesion on the right side of her epiglottis. On the basis of findings of laryngofiberscopy, computed tomography, and magnetic resonance imaging, she was preoperatively diagnosed as having a congenital laryngeal cyst. She was referred to our department at the age of 24 days. We performed endoscopic marsupialization of the cyst by inserting a rigid endoscope through the oral cavity at the age of 28 days. The laryngeal cyst was located on the right arytenoid and aryepiglottic fold. Histologically, the cyst wall was lined with a stratified squamous epithelium. These findings were compatible with a ductal cyst. The patient’s postoperative course was satisfactory, and no evidence of recurrence or respiratory disorder was noted for 3 months after surgery. Because neonatal laryngeal cysts can cause severe respiratory disorders, neonates with laryngeal cysts require airway management and treatment as soon as possible. We recommend endoscopic marsupialization for the treatment of laryngeal cysts in neonates because of its minimal invasiveness, safety, and effectiveness.
A 2-years old boy was brought to our hospital because of fever, bloody vomit, and poor appetite. Plain chest X-ray and abdominal CT images showed intraabdominal free air; therefore, he was diagnosed as having upper gastrointestinal perforation. We performed an emergency operation by a laparoscopic procedure, and perforation (4.0 mm in diameter) of the duodenum was confirmed on the anterior duodenal bulb. We performed laparoscopic omental implantation and thoroughly irrigated the abdominal cavity. The postoperative course of the patient under treatment with antibiotics and a proton pump inhibitor was uneventful. He was discharged on the 5th postoperative day. We diagnosed him as having perforated duodenal ulcer. We were able to perform laparoscopic surgery as in adults without postoperative complications. We consider that laparoscopic surgery is useful for both diagnosis and treatment of infants with perforated gastric ulcer. We report a successful treatment of a rare pediatric case with perforated duodenal ulcer using laparoscopic surgery.
The patient was a girl aged 1 year and 8 months, in whom treatment of abdominal lymphangioma had been planned. A nearby hospital referred her to us for paleness, abdominal distension and severe anemia, which had persisted from the previous day. Despite the initial diagnosis of hemorrhagic shock due to hemoperitoneum, CT did not reveal any signs of bleeding. After she was admitted into the intensive care unit (ICU), the condition of shock became worse again and bleeding from lymphangioma was observed; thus, interventional radiology (IVR) was performed. Hemoperitoneum with hemorrhagic shock due to lymphangioma is rare and has not been reported in the literature.
We report the case of a 20-year-old female patient who underwent the Frey procedure using the double Roux-en-Y technique for chronic pancreatitis and postoperative complications after hepaticojejunostomy for congenital biliary dilation (CBD). She underwent laparoscopic cholecystectomy owing to the idiopathic perforation of the gallbladder at 4 years of age and hepaticojejunostomy for CBD at 7 years of age. However, she previously experienced repeated episodes of acute pancreatitis despite no clear evidence of pancreas divisum on ERP or MRCP. Endoscopic sphincterotomy and stent insertion did not improve her symptoms. Enhanced CT revealed chronic pancreatitis with stone formation and the dilatation of the distal pancreatic duct at 19 years of age. The pancreatic calculus was removed and the Frey procedure using the double Roux-en-Y technique was performed to treat her chronic pancreatitis. Her abdominal symptoms improved after surgery. Surgery should be selected for patients with chronic pancreatitis with pancreatic calculus and who respond poorly to conservative management. The Frey procedure using the double Roux-en-Y technique is a safe and effective intervention for chronic pancreatitis in patients with postoperative CBD.
We report a rare case of acute appendicitis complicated by familial food poisoning caused by poisonous mushroom. An 11-year-old boy ate mushrooms that were gathered from a mountain, which his family also ate. His mother, brother and the patient experienced nausea and abdominal pain three hours after eating. They monitored themselves for a while, but the next morning, the patient felt severe abdominal pain in the right lower quadrant. The patient then visited our hospital. Blood examination showed a high number of white blood cells. Furthermore, abdominal CT showed enlargement of the appendix and accumulation of ascitic fluid; thus, we diagnosed him as having acute appendicitis, and laparoscopic appendectomy was performed. The appendix was enlarged and reddish; moreover, the ileum became edematous associated with extensive ileitis. An examination of the mushrooms that they ate revealed that they were ‘Tsukiyotake’, which are poisonous. We hypothesized that ileitis caused edema of the ileocecal area and acute appendicitis.
The patient was a 0-day-old boy. He was born without an anus in a nearby hospital and diagnosed with anorectal malformation (ARM); thus, he was taken to our hospital 2 h after birth. He was subjected to invertogram and urethrocystography 22 h after birth and diagnosed as having low ARM without a fistula. He was subjected to invertogram again to confirm the distance of dimple to the rectal blindness edge 40 h after birth, and perineal anal formation was performed 44 h after birth. His postoperative course was good, but his CRP level on the first day of looking unwell was 11.4 mg/dl, and abdominal distension gradually developed. Abdominal X-ray suggested the presence of free air in the peritoneal cavity, and he was operated for gastrointestinal perforation. In the operation fields of view, perforation was found in the anterior wall of the rectum above the peritoneal reflection, and an interruption in the circulation in part of the perforation was detected. We sutured the perforation, performed colostomy, washed the abdominal cavity, and inserted a drain tube. Free air was already found to exist in the second invertogram when we reviewed an X-ray image after operation. It is necessary to recognize that ARM can possibly lead to idiopathic rectal perforation.
A 12-year-old girl presented to a physician with the complaint of left-upper-quadrant pain. Abdominal ultrasonography showed a round mass in the tail of the pancreas, and she was referred to our department. Enhanced computed tomography and magnetic resonance imaging (MRI) revealed an encapsulated, heterogeneous solid mass measuring 40 mm in diameter in the distal part of the pancreas. She was diagnosed as having solid-pseudopapillary neoplasm (SPN) of the pancreas. Laparoscopic spleen-preserving distal pancreatectomy with conservation of splenic vessels was performed. She resumed oral intake in POD2. Postoperative pancreatic fistula (International Study Group of Pancreatic Fistula; Grade B) occurred and was treated conservatively. The functional and aesthetic results were satisfactory, and no recurrence was found on MRI one year after surgery. A pair of 3 mm forceps was useful and enabled meticulous handling, such as dividing the splenic vessels from the pancreatic substance. The laparoscopic spleen-preserving distal pancreatectomy is minimally invasive and safe for benign or low-grade malignant tumors of the distal pancreas in children.
Anterior cutaneous nerve entrapment syndrome (ACNES) is relatively unknown as a cause of abdominal wall pain, and pediatric cases in Japan are almost never recognized. We reported two cases of ACNES in children. Case 1: A 14-year-old female was referred to our department with right lower quadrant (RLQ) abdominal pain during activity. Blood examination and CT and MRI showed no abnormalities, but Carnett’s test was positive. We performed rectus sheath block for progressive pain, but the pain still persisted. Four months after the consultation, neurectomy was performed. Case 2: A 9-year-old male was referred to our department with a 9-month history of RLQ abdominal pain of unknown cause. Blood and imaging test showed no abnormalities but Carnett’s test was positive; therefore, we suspected ACNES. We performed neurectomy without injection therapy because his family wished only for this operation to be performed. The number of reported cases of ACNES has increased in recent years, and there may be many cases in which it is the cause of chronic abdominal pain. It is important for practitioners to be aware that ACNES may be detected by physical examination in the absence of any abnormal laboratory findings. Although local injection therapy is effective to some extent, neurectomy is a radical and effective treatment.
We report the case of 12-year-old premenarcheal girl. A year ago, she was diagnosed as having left ovarian non-neoplastic torsion, and an emergency operation was performed to release the torsion and fix it. Within the follow-up period, a cystic lesion in the affected ovary increased in size, accompanied by abdominal pain. Abdominal ultrasonography and Magnetic resonance imaging revealed a simple cyst, but it rapidly increased in size to 17 cm 1 year after the operation. During the follow-up period, tumor markers (AFP, HCG-β, and CA125) were within normal range. Surgery was performed to remove the cystic lesion. We considerded the lesion as cystic teratoma, serous/mucinous cystadenoma or ovarian simple cyst preoperatively diagnose. By umbilical Ω incision, we aspirated the cystic contents. The contents were yellow transparent mucus. After depressurization, we pulled up the left ovary from the incision and found no evidence of torsion. We confirmed no solid components in the lesion and performed cystectomy. On the basis of histopathological examination findings, she was diagnosed as having ovarian endometriosis. It is very rare for endometriosis to develop before menstruation. Long-term observation is necessary to determine the possibility of infertility associated with adhesion in the pelvis and pain after menstruation onset.
A 16-month-old boy presented with cylindrical umbilical hernia the size of the tip of a thumb. We considered him as a candidate for hernia repair surgery and umbilicoplasty. After closing the hernia using a standard procedure, the skin incision line was extended through the umbilical upper fold to the circumferential fold. Redundant skin in the dermal layer was excised, leaving subcutaneous tissue, and then the tissue and skin were circumferentially sutured. Pressure was added to the bottom of the umbilicus using a gauze ball for one week after the surgery to form an umbilical dimple with a near-normal appearance. The appearance and structure of the restructured umbilicus remained near-normal for two years. The skin of most giant umbilical hernias often shrinks over time after umbilicoplasty, therefore causing difficulties while maintaining a near-normal postoperative umbilical structure over the long term. The skin is less likely to shrink after applying our technique because the bottom part of the umbilicus is used, and hiding the incision within the new umbilicus provides a cosmetically satisfactory result. This could be applicable for umbilicoplasty with the redundant skin of proboscoid hernias.
We herein report a case of biliary atresia (BA) in a preterm female infant delivered by caesarean section on the 33rd week of gestation. Her birth weight was 1,425 g. Her stool color changed from green to gray after the 7th day of age. Therefore, both abdominal ultrasonography and biliary scintigraphy were performed, and on the basis of the results of which, BA was suspected. We carefully observed her stool color and serum bilirubin level and monitored her weight gain. On the 37th day of age (corrected age: 38 weeks, 5 days of gestation), laparotomy for accurate diagnosis was performed. Intraoperative cholangiography showed BA (I-b1-β), and then Kasai’s portoenterostomy was carried out. On the 45th day after the procedure, she was discharged and her postoperative clinical course continued to be uneventful for 5 months after the discharge. In Japan, BA infants with very or extremely low birth weight are very rare, estimated to be less than 1% of BA infants. Unfortunately, there are only a few studies clarifying the operation timing and postoperative prognosis in such BA cases. Therefore, on the basis of our experience and the literature, we discussed Kasai’s operation timing for biliary atresia in preterm infants or very low birth weight infants.