Purpose: To prevent nutritional and hepatic disorders and intestinal disuse atrophy in premature infants with jejunostomy/ileostomy, we have performed frequent and safe infusion of intestinal fluid through an indwelling distal intestinal tube and a divided stoma.

Methods: The cases of seven premature infants who underwent infusion of intestinal fluid into distal jejunostomy/ileostomy in our department from 2014 to 2016 were reviewed retrospectively.

Results: There were four infants with necrotizing enterocolitis, two with meconium-related ileus, and one with focal intestinal perforation. Jejunostomy and ileostomy were placed in four and three patients, respectively, and double-barreled, divided, and loop stomata were created in three, three, and one, respectively. A distal intestinal tube was inserted on postoperative days 20–92, and intestinal fluid was collected and infused into the distal stoma through the tube every 1–3 hours. A divided stoma made these procedures safe and easy since no pouch was needed for a distal stoma, and the inserted tube was easy to maintain. After starting the infusion, weight increased and hepatic disorder improved in seven and four patients, respectively. No complications directly from these procedures were observed. Seven patients underwent stoma closure after 20–149 days of intestinal fluid infusion.

Conclusions: The infusion of intestinal fluid through an indwelling tube in the distal stoma was found to be safe and easy, and seemed effective for realizing weight gain. A divided jejunostomy/ileostomy was also useful for easy and safe infusion, and stoma and tube management. Further study will confirm the present results and reveal a better procedure.

Purpose: We evaluated rectoanal functions five years after surgical procedures for each type of Hirschsprung’s disease (HD).

Methods: Between 1991 and 2010, 105 patients with HD underwent surgical procedures at our hospital. The surgical procedures and types of HD were as follows: transanal endorectal pull-through (TA), open Soave procedure (O-SO), and open Duhamel procedure (O-DU) for 51, 26, and 7 patients with the short type (SHORT), SO and DU for 6 and 5 patients with the long type (LONG), and SO, DU, and the Martin procedure (MA) for 2, 2, and 6 patients with the total type (TOTAL), respectively. Rectoanal functions (soiling, staining, frequency of defecation, constipation, and urge to defecate) were analyzed partially on the basis of clinical assessment scales for bowel functions of the Japanese Study Group of Anorectal Anomalies.

Results: In patients with SHORT, there was no significant difference in rectoanal functions among surgical procedures. The staining scores 5 years after the operation were higher in patients treated by TA and O-SO than in those treated by O-DU. The constipation scores were higher in those treated by O-DU than in those treated by the other procedures. No significant difference in each score was found in patients with LONG. The incontinence, staining, and frequency of defecation scores in patients with TOTAL treated by SO were poorer than those in patients treated by the other procedures.

Conclusion: Five years after surgery, staining tended to occur in patients treated by SO and constipation tended to occur in patients treated by DU. Although further investigation and long-term follow-up are needed for each surgical procedure, appropriate surgical procedures should be selected and rectoanal functions should be managed according to the type of HD for QOL improvement.

Purpose: The treatment of giant cystic meconium peritonitis (GCMP) is difficult in the presence of strong inflammatory changes. For determining the optimal treatment, we retrospectively reviewed the treatments in our GCMP case series.

Methods: We reviewed the medical records of six patients with GCMP treated from 2000 to 2015 at our institution. We divided these patients into two groups according to the type of treatment, enterostomy (enterostomy group: EG, n = 4) or drainage (drainage group: DG, n = 2), at the initial surgery.

Results: Six patients were diagnosed as having meconium peritonitis prenatally. The median gestational age was 35.5 weeks (34–38 weeks) in EG and 34 weeks (31 and 37 weeks) in DG. The median birth weight was 2,647 g (2,526–2,777 g) in EG and 2,551 g (2,397 and 2,705 g) in DG. In DG, the operation time was shorter and the amount of bleeding was smaller. On the other hand, the postoperative nutritional start was earlier in EG. Patient 6 underwent surgery three times, but the others did twice. The duration from the first surgery to radical surgery was over 30 days in all patients. The complications were abdominal wall hernia in one patient and anastomotic stenosis in one patient in EG, and liver dysfunction in two patients in DG. The median follow-up period was 37.5 months (16–186 months). Except for the patient with trisomy 21, the other patients have shown normal development.

Conclusion: We obtained a good outcome by performing enterostomy or drainage at the first surgery followed by radical surgery after 30 days. Multistage surgery could be an option in the treatment of GCMP.

Purpose: The aim of this study is to compare the postoperative outcome between laparoscopic percutaneous extraperitoneal closure (LPEC) and the Potts procedure for pediatric inguinal hernia in patients with ventriculo-peritoneal (VP) shunt.

Method: A comparative review of nine patients subjected to LPEC from 2011 to 2017 and nine patients subjected to the Potts procedure from 2006 to 2010 was carried out in terms of the background of the patients, the occurrence rate of bilateral inguinal hernia, the recurrence rate, and the complications related to the VP shunt.

Result: Seven patients (78%) in the LPEC group and six patients (66%) in the Potts procedure group were subjected to inguinal hernia repair on both sides. Intra-abdominal adhesion and peritoneal thickening were seen in three patients (33%). No statistically significant difference in operation time was found between the two groups. Although there was no recurrence of inguinal hernia after LPEC, recurrence occurred in one patient subjected to the Potts procedure. There was only one case of conversion from LPEC to the Potts procedure owing to the intra-abdominal adhesion and distention of the sigmoid colon. No complications related to the VP shunt were observed.

Conclusion: LPEC for patients with the VP shunt is a safer method than the Potts procedure. However, it is necessary to consider carefully which procedure should be chosen when the spermatic duct or testicular blood vessel is obscured owing to peritoneal thickening, intraperitoneal adhesion, or intestinal expansion, as well as when the body weight of the patient is under 3 kg.

Purpose: The age appropriate for operation for the repair of pectus excavatum in children is controversial. Early operation in young children may lead to recurrence after bar removal. In this study, we analyzed the vertebral index (VI) to elucidate the recurrence of chest depression 5 years after bar removal.

Methods: Thirty-six patients who underwent the Nuss procedure at less than 8 years of age and were followed up for more than 8 years were included in this study. We measured VI from lateral chest radiographic images 5 times in each patient before bar removal, immediately after bar removal, and 1, 3, and 5 years after bar removal. Five-year VIs were compared with preoperative VIs in 57 12- to 14-year-old patients with pectus excavatum.

Results: The average ages at operation and bar removal were 5.6 ± 0.9 and 8.0 ± 0.8 years, respectively. The average VIs before bar removal, immediately after bar removal, and 1, 3, and 5 years after bar removal were 20.4 ± 2.7, 23.3 ± 3.8, 24.4 ± 3.8, 26.8 ± 4.5, and 28.3 ± 5.8, respectively. There was no significant change in VI between immediately after bar removal and 1 year after bar removal. However, VI was significantly higher 3 and 5 years after bar removal than immediately after bar removal. The average preoperative VI in 57 patients was 34.8 ± 6.3, and it is significantly higher than that 5 years after bar removal. However, in 12 of 36 patients, the 5-year VI was high within the range of the preoperative VI.

Conclusions: Bar removal under 10 years of age is a risk factor for recurrence. Twelve of the 36 patients showed recurrence.

Purpose: We reviewed our experience in treating patients with Gross type-A esophageal atresia (EA) at a single institution to assess the clinical outcomes and problems.

Methods: A retrospective study was carried out for 12 patients with Gross A type EA who received surgical treatment at our institution.

Results: The patients were 7 males and 5 females, with gestational ages ranging from 26.4 to 41.6 weeks. Their birth weights ranged from 746 to 3,130 g. The associated anomalies were congenital heart disease in three infants, duodenal atresia and anorectal malformation in one, and congenital esophageal stenosis in one. A patient who had trisomy 18 did not undergo esophageal anastomosis. The median length of the gap between the upper and lower pouches was 4.5 vertebral bodies. Esophageal elongation was performed in accordance with the Howard procedure in six patients, Kimura’s technique in three, and the Foker technique in one. The duration required for esophageal elongation ranged from 15 to 337 days. Esophageal anastomosis was achieved at ages ranging from 0.8 to 14.5 months. Postoperative anastomotic stricture occurred in 10 of the 11 patients. These patients required multiple balloon dilatation, which resulted in the improvement of the symptoms in eight patients. However, two patients required resection of the esophageal stricture and re-anastomosis for the improvement of their symptoms.

Conclusion: Esophageal reconstruction using the patient’s own esophagus was successfully achieved in all patients. Partial resection and re-anastomosis are therefore considered to be effective treatments for severe refractory anastomotic stricture in EA patients.

A 12-year-old male patient, who was diagnosed as having retinal hemangioma and von Hippel-Lindau disease at age 8, was found to have a right adrenal tumor on ultrasonographic examination. Blood and urine tests revealed high catecholamine levels, and imaging studies demonstrated tumors in the right adrenal gland and left posterior mediastinum. With the diagnoses of right adrenal pheochromocytoma and left mediastinal paraganglioma, the tumors were safely resected by laparoscopic surgery but with transient hypertension. No malignancy was found on histopathologic examination of tumor specimens. The literature indicates that pheochromocytoma in von Hippel-Lindau disease tends to develop bilaterally and/or outside of the adrenal gland and rarely becomes malignant. Moreover, patients with von Hippel-Lindau disease are known to be predisposed to develop, simultaneously or metachronously, several kinds of tumors throughout the body. Therefore, it is important to select the appropriate follow-up or treatment in these patients.

Massive ovarian edema (MOE) is characterized by a substantial solid enlargement of the ovary, which is associated with interstitial edema, but does not display any neoplastic change. We here report two cases of MOE. Case 1: A 9-year-old girl presented with appetite loss, vomiting, and an abdominal mass. There was a 10 cm solid mass in the right lower abdomen. Magnetic resonance imaging (MRI) showed an enlarged ovary with a necklace sign (multiple follicles located peripherally), which is characteristic of MOE. At laparotomy, the right ovary was twisted and right salpingo-oophorectomy was performed. Case 2: A 4-year-old girl was admitted to our hospital because of abdominal pain and vomiting. MRI showed a mass with multiple follicles in the pelvis. From MRI findings and clinical experience, we made a preoperative diagnosis of MOE. During laparoscopy, release of the torsion and oophoropexy were performed. The above cases indicate that MOE should be considered in girls presenting with acute abdominal symptoms.

The traditional herbal Japanese medicine, hainosankyuto, has drainage and anti-inflammatory activities and is considered to be useful for treating perianal abscesses in pediatric surgery. If an abscess becomes chronic, juzentaihoto, another traditional herbal Japanese medicine with wound healing activity, is also considered as a suitable treatment for this condition. A 7-year-old boy had symptomatic epilepsy and spastic quadriplegia in infancy, which made oral intake difficult. At 5 years of age, he underwent gastrostomy but subsequently experienced repeated bouts of dermatitis around the gastrostomy site. Treatment included ointments and skin protective agents; however, the dermatitis worsened from approximately 7 years of age. Abdominal computed tomography (CT) at 7.5 years of age revealed an abdominal wall abscess. The administration of 0.3 g/kg/day hainosankyuto was initiated, after which the amount of exudate decreased and skin inflammation subsided within 1 month. Thereafter, treatment was switched to 0.3 g/kg/day juzentaihoto, which additionally reduced granulation. Abdominal CT after 4 months of treatment showed a remarkable improvement of the abdominal wall swelling and the disappearance of skin inflammation. We report favorable results achieved by administering hainosankyuto and juzentaihoto to a child with severe motor and intellectual disabilities whose treatment became difficult after the formation of an abdominal wall abscess owing to dermatitis around the gastrostomy site.

We herein report a case of gastric immature teratoma presenting as an oncologic emergency. Prenatal ultrasound showed a heterogeneous mass on the left kidney at 24 weeks of gestation and polyhydramnios at 26 weeks of gestation. Fetal magnetic resonance imaging showed a heterogeneous tumor including calcification. The prenatal diagnosis was teratoma. The male infant was born by elective Caesarean section at 36 weeks because of rapid tumor progression. He showed severe respiratory distress due to the huge tumor. An open biopsy was performed to determine the therapeutic strategy. The intraoperative rapid histopathological findings corresponded to neuroblastoma, and the urinary HVA and serum NSE levels were high. Chemotherapy was initiated before a definitive pathological diagnosis because of tumor enlargement. The ultimate pathological diagnosis was teratoma, so tumor extirpation was performed at 21 days of age after recovery from bone marrow suppression. The huge immature teratoma arose from the posterior wall of the stomach. The prenatal diagnosis of tumors is sometimes difficult. The treatment should be performed in cooperation with a pediatrician, a pathologist, and a radiologist.

An 18-month-old boy was examined at a local general hospital mainly because of an abdominal mass. On suspicion of right nephroblastoma, he was hospitalized for a more detailed examination. During the night on the day of admission, the patient developed tachycardia. Blood tests performed the following morning indicated anemia, and contrast-enhanced computed tomography (CT) revealed a large amount of ascites. Intraperitoneal bleeding and continuous bleeding caused by spontaneous tumor rupture were diagnosed, and the patient was transported to our hospital by air ambulance. We decided to perform transcatheter arterial embolization (TAE) prior to surgery to stabilize the patient’s general physical status. Selective right renal arteriography revealed extravasation, and embolization was performed using a gelatin sponge. Operation was performed the following day. The tumor capsule had ruptured; however, good hemostasis was achieved by TAE. The histopathological findings led to the diagnosis of nephroblastoma. TAE is rarely performed for bleeding caused by pediatric solid tumor rupture in infants particularly because the procedure is both complicated and difficult. However, in cases in which bleeding is difficult to control, it appears that TAE can contribute to the stabilization of the patient’s general physical status and help make subsequent treatments safer and quicker.

Pyriform sinus fistula (PSF) causes sudden onset of symptoms such as respiratory distress during the neonatal period. Here, we report the cases of three PSF patients who presented with respiratory distress in the neonatal period. In the first case, the patient showed a fever and respiratory disorder two days after birth. Cardiopulmonary arrest developed four days after birth, and cardiopulmonary resuscitation was performed. A mass on the left neck was noted, and a fistula was confirmed by cystography via puncture. The alleviative effect of the puncture of the cyst was temporary. The patient underwent resection 26 days after birth. In the second case, a mass on the left neck was noted two days after birth, and stridor aggravated it. A cyst with air bubbles was confirmed on magnetic resonance imaging. The patient needed endotracheal intubation because of dyspnea. The alleviative effect of puncturing the cyst was temporary, and because dyspnea continued, we resected the cyst 21 days after birth. In the third case, a mass on the left neck was noted during the prenatal period. The patient showed respiratory disorder after birth and underwent puncture of the cyst to alleviate respiratory symptoms and infection. Cystography showed a fistula. Because the respiratory symptoms persisted, we performed resection 26 days after birth. Puncturing a cyst is effective in relieving respiratory symptoms and infection in cases of PSF during the neonatal period, but the effect is temporary. Early operation should be considered in cases of neonatal PSF with dyspnea.

We report a case of strangulation ileus due to vitelline vascular remnants without Meckel’s diverticulum. A 14-year-old boy was admitted to our hospital with abdominal pain and vomiting. Ultrasonography and enhanced CT revealed a localized ischemia and distention of the intestine. We diagnosed him as having strangulation ileus and performed emergency open surgery. Upon surgery, we found a band running between the anterior surface of the mesentery of the ileum, 10 cm proximal to the ileocecal valve, and posterior abdominal wall of the umbilicus. The band caused strangulation ileus of the ileum, and no Meckel’s diverticulum was detected. The band was resected. Histopathological analysis revealed that the band contained an artery and a vein, and was diagnosed as vitelline vascular remnants. Reports of vitelline vascular remnants without Meckel’s diverticulum are very rare. In treating strangulation ileus in a patient who had no previous history of laparotomy, vitelline vascular remnants should be considered as a differential diagnosis.

A 13-year-old boy presented with fatigue. Laboratory data revealed anemia and an elevated C-reactive protein level. Abdominal sonography showed a highly echoic, heterogeneous mass in the spleen. Enhanced CT showed a low-density mass with an enhanced margin. Magnetic resonance imaging showed the mass as areas of iso-intensity and low intensity on T1- and T2-weighted images, respectively. Hand-assisted laparoscopic splenectomy was carried out because the possibility of a malignant neoplasm could not be ruled out. The tumor was histopathologically diagnosed as inflammatory pseudotumor (IPT) of the spleen. The preoperative diagnosis of IPT is complicated by the absence of specific radiological features. Splenectomy is generally necessary for patients with IPT of the spleen because such tumors might be malignant.

A 6-year-old girl was admitted to our hospital because of epigastralgia and vomiting. She was diagnosed preliminarily as having torsion of an ovarian cyst, but laparoscopic surgery showed no evidence of torsion but only a right ovarian cyst. Because she had a slight fever and epigastralgia after surgery, we performed ultrasonography and contrast-enhanced computed tomography scans, which showed a tumor at the porta hepatis. She underwent repeat surgery 37 days after the onset of symptoms because of the suspicion of gastrointestinal duplication or mesenteric lymphangioma. A 15-mm mass superior to the hepatic duct bifurcation was removed and shown histopathologically to be hepatic tissue with ischemic necrosis. The final diagnosis was accessory liver lobe with torsion. Her clinical course after surgery was good, and she was discharged 8 days after the second surgery. Accessory liver lobe is a congenital anomaly. Because accessory liver lobe does not have identifying features, it is difficult to diagnose using imaging modalities and is therefore usually diagnosed definitely at surgery or histopathologically. Accessory liver lobe is rarely detected owing to torsion, which gives rise to acute abdominal pain.

We present a rare case of congenital massive hiatal hernia (CMHH) with short esophagus in a neonate. A 4-day-old boy was transported to our hospital with a history of recurrent vomiting. Upper gastrointestinal series showed the presence of a short esophagus and an intrathoracic stomach. We started tube feeding, while maintaining the Fowler position, and administered antacids. At 68 days of age, we confirmed that the esophagus was longer than before by upper gastrointestinal series. At 75 days of age, he weighed 4,160 g and underwent successful laparoscopic repair. He was fed on postoperative day 11 and discharged on postoperative day 51. When we perform operation for CMHH, we must consider the possibility of complications such as a short esophagus. Elective surgery is a good option for patients with CMHH if the general condition is stable and growth by tube feeding is possible.

Rectal stenosis is a type of anorectal malformation and a very rare disease. We report a case of rectal stenosis caused by severe constipation with abdominal distention in a boy aged 2 years and 3 months. He had undergone internal medical treatment for constipation from birth at a nearby home doctor. In rectal examinations, rectal stenosis at 4 cm from the anal verge was found. We performed balloon dilatation surgery, but this was unsuccessful. Next, partial cicatrectomy of the stenosis was performed. Histopathological analysis showed active fibroblast proliferation, fibrosis, vascular hyperplasia, and a preserved muscular layer. A search for “congenital rectal stenosis” in Japanese medical journals identified only five reported cases in children over a 40-year period. There was no case in which transanal excision was performed. We consider that the stenosis can be removed from the anus depending on its position, and transanal resection is also indicated.

The patient was a 7-year-old boy. He was admitted to our hospital with severe abdominal pain. A cystic-like lesion with poor contrast effect and the whirl sign was detected by CT, but no signs of intestinal obstruction such as dilation of rostral intestine, abdominal distention, nausea, and vomiting were observed. We diagnosed him as having axial torsion of Meckel’s diverticulum (ATMD) and performed single-incision laparoscopic-assisted release of the torsion and wedge resection of the ileum. Although a preoperative diagnosis of ATMD has been considered difficult, we were able to preoperatively diagnose this patient on the basis of the fact that his Meckel’s diverticulum was on the antimesenteric side and could be distorted without involving the ileum. Appropriate surgical procedures should be selected for the release of the torsion of a cystic-like lesion without intestinal obstruction considering ATMD, and single-incision laparoscopic-assisted surgery for ATMD is useful.

A 12-year-old boy was brought to an emergency clinic owing to abdominal pain and vomiting for three days. He also had signs of peritoneal irritation, and an imaging examination revealed metallic foreign bodies and free air in the abdomen; he was therefore transferred to our institution. Emergent laparotomy was performed because gastrointestinal perforation induced by the foreign bodies was suspected. The foreign bodies were found to be magnets and metallic accessories. Two perforations were found at the site of adhesion of the intestine due to magnetic attraction, one between two parts of the small intestine and the other between the small intestine and the colon. All foreign bodies were removed and ileocecal resection and anastomosis were performed. The postoperative course was uneventful; however, the patient showed pica during recovery. After consulting a psychiatrist, the patient was diagnosed as having pica induced by psychogenic stress. Follow-up treatment was continued for 2 years after the operation. The accidental ingestion of multiple magnets is a risk factor for various gastrointestinal injuries, including fistula, penetration, perforation, and obstruction. In cases involving accidental ingestion by older children, the possibility of mental illness should be considered, in addition to the treatment of foreign body ingestion.