Purpose: Complicated appendicitis (CA) often needs to be managed surgically, and it is desirable that CA is diagnosed as soon as possible. The aim of this study is to identify a cutoff of the Pediatric Appendicitis Score (PAS) for CA in children.

Methods: Children who underwent appendectomy because of acute appendicitis in our hospital from May 2013 to September 2017 were enrolled in this study. We retrospectively identified a cutoff PAS for CA.

Results: One hundred twenty patients were included in the study, 75 of whom were male and 45 were female with a mean age of 10.3 years. Complicated appendicitis was found in 50 patients, and simple appendicitis (SA) was found in 70 patients. The histopathological diagnoses were gangrenous appendicitis (44 cases), phlegmonous appendicitis (71 cases), catarrhal appendicitis (3 cases), and normal appendix (2 cases). The PAS was significantly different between CA and SA (CA: median 8.0, IQR 7.3–9.0 vs SA: median 6.0, IQR 5.0–7.0, p<0.001). The area under the curve was 0.83 (95%CI: 0.80–0.93) based on the receiver operating characteristic curve. When the cutoff PAS was 8, the sensitivity was 0.74 and the specificity was 0.89.

Conclusion: The usefulness of PAS alone for the diagnosis of CA is limited. However, the PAS of CA is significantly higher than that of SA, and a child with a PAS of more than 8 is strongly suspected of having CA. Computed tomography can be performed when ultrasonography is inconclusive.

Purpose: The stool color card for screening biliary atresia (BA) has been available in Japan since 2012. However, many BA patients treated in a hospital are over 3 months old. We sought to evaluate medical health professionals’ understanding of BA and use of the stool color card to help improve their knowledge and practice.

Methods: We administered a questionnaire survey, with the aim of developing an educational campaign for medical health professionals at our institution, which included pediatricians, obstetricians, nurses in children’s and maternity wards, and midwives.

Results: A total 109 of 172 (63.3%) medical health professionals responded to our questionnaire. Thirteen (11.9%) respondents stated that they were unfamiliar with the color card. Thirty-nine (35.7%) said that they could not identify the stool color without using the color card. However, 105 (96.3%) respondents had good knowledge of BA and 59 (54.1%) knew that patients with BA are diagnosed within 1 month of age. Forty-five (41.2%) providers believed that BA can be completely cured.

Conclusions: The results of our questionnaire showed that apart from pediatric surgeons, there is little understanding of BA among medical professionals. Health professionals and parents must be educated about the importance of BA and instructed in the proper use of the stool card.

We report the case of an 8-year-old boy with Ewing’s sarcoma family of tumors of the right chest wall after treatment. He was initially diagnosed at 4 years of age. The patient achieved remission by multidisciplinary therapy. One year and nine months later, computed tomography showed a liver metastasis of 23 mm diameter located in segment 6 and a lung metastasis. After neoadjuvant chemotherapy, laparoscopic partial hepatectomy was performed for the liver metastasis at 7 years of age. Subsequently, he underwent lung resection and postoperative chemotherapy. Eleven months later, CT revealed a liver metastasis of 16 mm diameter in segment 2. We performed a second laparoscopic partial hepatectomy when he was 8 years and 8 months of age. Mild adhesion was observed at the previous surgical site of the liver, but there were no adhesions in the left lateral segment, which enabled us to operate safely. No transfusion was required during either of the perioperative periods of the laparoscopic surgeries, and there were no postoperative complications. Laparoscopic hepatectomy has become commonly used in adults, but there are only a few reports on its use in pediatric cases. Laparoscopic surgery is minimally invasive and causes less adhesion. This case demonstrates that laparoscopic surgery is useful for pediatric patients with a high risk of recurrence.

Chronic radiation enteritis may occur more than 6 months after radiotherapy owing to ischemic changes of the intestine. Patients with severe radiation enteritis require surgical treatment. Because chronic radiation enteritis may develop even long after the radiotherapy for malignant disease ends, the risk of occurrence should always be considered. We report a case of peritonitis due to intestinal perforation secondary to chronic radiation enteritis 10 years after radiotherapy, and surgical management to treat the intestinal condition was required four times. The patient was a 25-year-old woman who had received chemoradiotherapy over 5 years since the age of 10 for a pelvic rhabdomyosarcoma Stage IV and achieved complete remission. She had undergone pelvic irradiation twice at a total dose of 95.4 Gy. We resected the perforation site and tried to anastomose the remaining small intestine located in a previous radiation field twice, but all such attempts failed. After the fourth operation including ileocecal resection, the residual small intestine became about 100 cm in length. Then, home parenteral nutrition (HPN) was required for 9 months. The optimal surgical method should be considered according to condition of the disease in individual patients for the treatment of chronic radiation enteritis.

The patient was an 18-year-old woman who underwent resection of an extrahepatic bile duct at the age of 2 under the diagnosis of congenital biliary dilatation. She presented with upper abdominal pain and nausea when she visited a clinic. Imaging findings showed intrahepatic cholelithiasis with dilatation of bilateral intrahepatic bile ducts. We performed double-balloon enteroscopy (DBE) to retrieve biliary stones through Roux-en Y anastomosis. During enteroscopy, she frequently complained about epigastralgia, and she was diagnosed as having severe acute pancreatitis induced by the procedure. She underwent conservative treatment with a satisfactory clinical course and was discharged 57 days after the onset. Several mechanisms such as mechanical strain on the pancreas and stimulation of papillae could be responsible for the post-DBE pancreatitis. Some reported that the duration of enteroscopy and the insertion depth of the scope could be related to pancreatitis. Although DBE is recognized as a minimally invasive method, it could carry a risk of pancreatitis. It is important to inform patients of this possible complication prior to performing DBE and to consider the duration of treatment.

The patient in the present case was a 2-day-old boy with a cystic lesion in his left testis, which was detected during the prenatal period by a maternal ultrasound examination at 34 weeks of gestation. At 37 weeks of gestational age, the 2,890 g boy was delivered by caesarean section. A cystic lesion of 10 mm size was recognized in a postnatal imaging examination, but no apparent solid or fat component was noted. A simple cyst or an epidermoid cyst was suspected. Considering the possibility of testicular atrophy due to a cystic lesion, we performed an operation at 1 month of age, which revealed a monoclastic cyst with a clear edge, which only nucleated the cyst. Histopathological analysis revealed squamous epithelial cells on the cyst wall surface, fibromuscular tissue, and intestinal tissue. Mature cystic teratoma was the diagnosis based on the examination findings of extirpated tissue. As shown in this case, the prenatal diagnosis of testicular tumors in the scrotum is very rare. In this case, a simple testicular cyst was initially considered to be the most likely diagnosis because no solid component was recognized on imaging after birth. In neonatal patients with testicular tumors, even lesions that only contain a cyst require a careful diagnosis and treatment with the possibility of germ cell tumors kept in mind.

Most cases of Meckel’s diverticulum are asymptomatic, but it can cause various symptoms. We report a rare case of Meckel’s diverticulum penetrating the abdominal wall and forming a bladder anterior cavity abscess. A 6-year-old boy had a lower abdominal pain in the last 4 days. He complained of an increase in the severity of abdominal pain and fever, and he was brought to a clinic. Owing to suspicion of gastrointestinal perforation, he was brought to our hospital for emergency treatment and emergency surgery was conducted on the same day. Laparoscopic observation showed that Meckel’s diverticulum penetrated the abdominal wall and formed a bladder anterior cavity abscess. We performed resection of Meckel’s diverticulum and abscess drainage. His postoperative course was uneventful. Histopathological analysis revealed ectopic gastric mucosa at the tip of Meckel’s diverticulum. Perforated ulcer was formed in the intestinal mucosa near the boundary between the ectopic gastric mucosa and the normal intestinal mucosa. Although preoperative diagnosis is difficult, exploratory laparoscopy enabled intraoperative diagnosis and a good postoperative course.

The patient was a 12-month-old boy in whom an intraabdominal cystic lesion was detected on fetal ultrasound examination performed at 21 weeks of gestation. Postnatal abdominal ultrasound revealed a hypoechoic image of about 20 mm size with a septal wall near the lower liver and the right kidney, which was monitored with suspicion of a mesenteric cyst. At 7 months of age, abdominal ultrasound and abdominal MRI showed that the cyst had increased in size, and the patient was introduced to our department. Laparoscopic observation at the umbilical incision with the suspected mesenteric cyst was carried out at 18 months of age. An ileocecal ileal duplication of about 4 cm size was detected, and an attempt was made to nucleate it, but a single-incisional laparoscopic-assisted ileocecal resection was performed in order to cause a stenosis. The mass did not block the intestine and lumen, and the fluid was mucous. A histopathological examination showed a cystic lesion and a muscle layer partially continuous from the proper muscle layer of the ileum, and the lumen is covered with MUC5AC(+) and MUC2(–) columnar epithelia. It was accompanied by a MUC6(+) pyloric-gland-like intrinsic gastric gland. Postoperatively, the patient progressed without signs of stenosis and was discharged on the 4th postoperative day.

A 14-year-old boy complained of abdominal pain, and he was admitted to our hospital with a diagnosis of bowel obstruction. A computed tomography of the abdomen revealed stenosis of the ileum. Three days after admission, laparotomy revealed an anomalous congenital band, which extended from the ileum to the mesentery, and asymptomatic Meckel’s diverticulum, which was located close to the oral side of the band. We performed simple resection of the band and Meckel’s diverticulum. His abdominal pain recurred 10 days after the first operation, and computed tomography revealed restenosis of the ileum. We performed laparotomy12 days after the first operation. The stenosis was caused by the adhesion between the band and the resection site of Meckel’s diverticulum. Therefore, we performed partial resection of the ileum. His postoperative course, after the second surgery, was uneventful with no recurrence of bowel obstruction. Bowel obstruction caused by an anomalous congenital band excluding omphalomesenteric duct remnants and vitelline vascular remnants is rare. Furthermore, an anomalous congenital band with asymptomatic Meckel’s diverticulum is extremely rare. Although simple resection is usually opted for asymptomatic Meckel’s diverticulum, our observations indicated that partial resection of the ileum should be one of the surgical choices to treat bowel obstruction caused by an anomalous congenital band with asymptomatic Meckel’s diverticulum.