Purpose: With the popularization of button batteries, many childhood cases of accidental button battery ingestion have been reported, but few treatments have been clearly described. We will summarize 33 cases of accidental ingestion of button batteries in our department and discuss our treatment algorithm.
Methods: We retrospectively summarized the 33 cases that we experienced treating in our department from 2008 to 2017 on the basis of medical records.
Results: There were 33 cases (17 boys and 16 girls; median age, 1 year 4 months) involving 37 batteries. There was no marked difference in the battery diameter by age. The battery locations on X-ray images at the initial visit were the esophagus (2), stomach (22), and intestinal tract (13). Regarding the battery diameter by location, significant differences were found between the esophagus and stomach, and between the esophagus and intestinal tract.
Conclusions: Regarding the treatment strategy for battery ingestion, batteries in the esophagus should be extracted early with an endoscope, and endoscopic observation should be performed after extraction, with reexamination at a later date if possible. Batteries in the stomach should be removed under fluoroscopy or under an endoscope if removal under fluoroscopy is difficult. Patients with batteries in the intestinal tract should be followed up with abdominal X-ray observation if they are not passed after three days. Surgical removal should be considered when symptoms occur regardless of the location of the battery in the digestive tract.
Purpose: Pancreatic masses are rare in children. We studied the clinical presentation and imaging findings to establish a differential diagnosis of pancreatic masses in children.
Methods: We reviewed the medical records of children diagnosed as having pancreatic masses on the basis of ultrasonography (including antenatal ultrasonography), computed tomography (CT), or magnetic resonance imaging findings across 7 hospitals between April 2005 and March 2017. We analyzed symptoms, imaging findings, treatment administered, and prognosis.
Results: Of the 17 children enrolled in this study, 5 were diagnosed as having SPN and 5 as having acute peripancreatic fluid collection/pancreatic pseudocyst (APFC/PPC). Pancreatic teratoma, acinic cell carcinoma, insulinoma, metastatic pancreatic tumor, and an intrapancreatic accessory spleen were diagnosed in 1 child each. On the basis of imaging findings, 2 lesions were diagnosed as congenital true pancreatic cysts. The masses were symptomatic in eleven cases. Six masses were detected through imaging studies for abdominal trauma. Dynamic CT of the pancreas revealed gradually increasing contrast enhancement in 3 children with SPN. Of the 5 children diagnosed as having SPN, we were unable to identify the tumor capsule in 2 children, and calcification (a characteristic finding in SPN) was observed in 4 children.
Conclusions: Pancreatic masses in children include benign and malignant tumors; however, most tumors identified in our case series were SPN and APFC/PPC. Imaging studies performed to diagnose SPN in children did not necessarily reveal the characteristic findings of SPN. However, the gradually increasing contrast enhancement observed on dynamic CT would be a useful diagnostic modality.
Purpose: The fecal disimpaction effect of sodium amidotrizoate meglumine solution (gastrografin®), a water-soluble gastrointestinal contrast medium, has been empirically recognized, but the clinical evidence has not been established. We examined the fecal disimpaction effect of gastrografin® in chronic constipation cases as a prospective observational study (cohort study).
Methods: From May 2015 to July 2016, patients from 1 to 16 years of age, with the chief complaint of constipation and diagnosed on the basis of Rome III criteria, and patients with a rectal diameter of 27 mm or more as determined by ultrasonography were included in this study. Seven to 10 days after gastrografin® enema, defecation was confirmed and the rectal diameter was reevaluated.
Results: Of the 157 patients included, 64 were examined. The median age was 4.2 years, 41 were boys, and the average rectal diameter was 38.1 mm at the first visit. In 33 patients, the rectal diameters were normalized to less than 27 mm and reduced in 57 patients until reexamination. The Bristol stool scale scores were on average 3.2 at the first visit and 4.6 at the return visit, and the feces significantly softened.
Conclusions: In this study, we showed the possibility of gastrografin® having a fecal disimpaction effect. This may be due to the softening of the feces through the osmotic effect. In patients whose ultrasonography revealed fecal impaction and a rectal diameter expanded to 27 mm or more, it is necessary to intervene aggressively from the early stage, and the results of this study showed that gastrografin® enema is useful.
Purpose: We reviewed our experience in treating patients with congenital laryngeal atresia to evaluate their clinical outcomes and the problems encountered when treating them.
Methods: This retrospective study included nine patients with congenital laryngeal atresia, who were managed at our institutions between 1982 and 2017.
Results: Seven patients developed fetal ascites. A prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS) was made at a median gestational age of 21 weeks in five patients. EXIT procedures were performed in four of five patients with CHAOS. In the other two patients who were dichorionic diamniotic twins, intrauterine fetal death occurred in one of the twins owing to fetal heart failure. The airway was successfully accessed in the four patients in whom tracheostomy was performed under an EXIT procedure. Although tracheostomy was performed immediately after birth in four patients in whom CHAOS was not prenatally diagnosed, the patients died of hypoxemia, except for one patient with tracheoesophageal fistula and esophageal atresia. The median gestational age of the neonates was 37 weeks, and the median body weight was 2,015 g. Congenital anomalies were confirmed in five patients. Five patients survived during the neonatal period, whereas two patients died owing to complications of the underlying diseases. Long-term survival was only achieved in three patients.
Conclusion: We concluded that the EXIT procedure was effective for the airway management of fetuses with congenital laryngeal atresia and that it improved the outcomes of such patients.
A girl who had been diagnosed as having trisomy 18 at 30 weeks of gestation was born at 32 weeks of gestational age with a body weight of 1,013 g. According to the prenatal explanation and discussion, she was intended to receive standard care treatment only. However, the parents wished mechanical ventilation for her dyspnea, and the treatment strategy gradually became aggressive. At six days of age, she underwent gastrostomy and lower esophageal banding for type C esophageal atresia. Her cardiac disease was patent ductus arteriosus only, which was ligated at 1 month of age. Tracheotomy was performed at 6 months of age, and she was discharged to home at 10 months of age. Thereafter, because saliva aspiration from the upper esophagus became difficult, repair for esophageal atresia and removal of lower esophageal banding were performed at the age of 1 year and 10 months. Although anastomotic stenosis requiring dilation developed postoperatively, she acquired some ability for oral intake and showed gradual and slight growth and development. When determining the medical care of newborns with severe disease, healthcare providers and patients’ families must fully discuss all options. We encountered difficulties in determining the repair for esophageal atresia after lower esophageal banding in the current patient because it was an almost unprecedented treatment. The experience of managing this patient has provided many lessons for us.
A 4 year and 10 month boy presented with intermittent abdominal pain occurring for several days, and intussusception was revealed by abdominal ultrasonography. Suspected of having Peutz–Jeghers syndrome because of the pigmentation on his lower lip and family history, he was referred to our hospital for further examination and treatment. After confirming the intraluminal polypoid lesion at the intestinal intussusception site by abdominal CT, single-balloon enteroscopy (SBE) was conducted under general anesthesia. Polyps (25 and 8 mm) were found at the upper jejunum 60 cm from the incisor, and polypectomies were subsequently performed safely and successfully. Balloon-assisted enteroscopy (BAE) was first developed in Japan in 2000 and has been used widely in adults. However, in the pediatric population, the use of BAE is still uncommon; furthermore, the use of SBE is rarely reported. Our present experience suggests that SBE is feasible for the diagnosis and treatment of small bowel lesion even in children.
We report a case of nonoperative management of perforated duodenal ulcer in childhood. A 14-year-old male was transported to a hospital by ambulance for abdominal pain. He showed a temperature of 37.5°C, epigastric abdominal pain, and localized muscular defenses. On examination, intraabdominal free air was observed on computed tomography and X-ray images. We diagnosed him as having a perforated duodenal ulcer. The patient’s general condition was good; therefore, we followed nonoperative management in accordance with the Evidence-based Clinical Practice Guidelines for Peptic Ulcer 2015 published by The Japanese Society of Gastroenterology. Conservative therapy included fasting and administration of drips, antibiotics, and antiulcer drugs. The patient’s temperature and abdominal pain improved on day 2. Oral intake resumed on day 5, and he was discharged on day 8. Because Helicobacter pylori (H. pylori)-immunoglobulin G antibody remained above the normal level, we suspected that the cause of duodenal ulcer was an H. pylori infection. Upper endoscopy showed scarring of the perforated duodenal ulcer of the bulbus. We performed eradication therapy for H. pylori and observed the boy on an outpatient basis. The duodenal ulcer did not recur. Given the outcome of this case, we think that the nonoperative management of perforated duodenal ulcer is a suitable treatment option for pediatric patients.
Life prognosis and quality of life have improved in patients with persistent cloaca, cloacal exstrophy, and disorders of sex development; however, the long-term reproductive function of these patients is not satisfactory. In this study, we aim to determine the optimal surgical timing and operative strategy in feminizing genitoplasty (vaginoplasty). In Keio University Hospital, a multidisciplinary team consisting of experts in pediatric surgery, pediatrics, urology, and gynecology is formed, and tailored treatment is provided for each patient. In this study, the cases of 5 patients (two had persistent cloaca and the other three had either cloacal exstrophy, congenital adrenal hyperplasia, or primary hypogonadism) who underwent feminizing genitoplasty were retrospectively reviewed. The length of the common channel, each patient’s wish, and past surgical history were all taken into account to determine the operative method that each patient underwent. A patient with persistent cloaca and a long common channel underwent the vaginal substitute method (intestinal canal). The other patient with persistent cloaca had strong adhesion and required regenitoplasty by the skin-flap method. The cloacal exstrophy patient underwent vaginal re-pull-through. The congenital adrenal hyperplasia patient had vaginal stenosis after the previous partial urogenital mobilization and required total urogenital mobilization. In the patient with primary hypogonadism, the pelvic peritoneum was utilized to create a neovagina. All but one patient experienced fair postoperative conditions with adequate vaginal patency. Given the variety of diseases requiring feminizing genitoplasty, drawing a tailored roadmap of the treatment strategy and optimal timing by a multidisciplinary team from the infancy period is essential to fulfill each patient’s need.
We report a case of a 12-year-old girl with sialoblastoma of the submandibular gland. She had a mass of 2 × 2 cm size in the left-sided submandibular since birth. The mass did not grow. We diagnosed the swelling lymph node by clinical examination. She and her family wanted the tumor to be removed, and we completely removed it under general anesthesia. Histopathologically, the tumor was diagnosed as sialoblastoma. Sialoblastoma is an extremely rare congenital salivary gland tumor with malignancy. In the literature, we found 50 cases of sialoblastoma, although this case is the first report in Japan. No recurrence was observed one year after the tumor resection.
Enteric duplication can induce intestinal obstruction in neonates. We evaluated the pathogenetic mechanism of neonatal bowel obstruction related to enteric duplication in three of our own cases and in cases reported in the Japanese literature.
Case 1: A 3,540 g full-term female neonate was referred to us on Day 3. Emergency laparotomy was performed and an enteric duplication measuring 5 cm in diameter was found in the ileocecum. The ileum had invaginated into the cecal fossa, which caused an internal hernia. Case 2: A 3,544 g full-term male neonate was referred to us on Day 2. Emergency laparotomy was performed and two enteric duplications measuring 0.7 cm and 2 cm in diameter were found on the mesentery side of the terminal ileum. The enteric duplications were compressing the adjacent ileal lumen. Case 3: A 2,896 g full-term female neonate was referred to us on Day 22. Emergency laparotomy was performed and an enteric duplication measuring 2 cm in diameter was found on the mesentery side of the terminal ileum. The enteric duplication was compressing the adjacent ileal lumen. In all three cases, we performed emergency resection of the enteric duplications with the adjacent intestine owing to intestinal obstruction. We diagnosed the enteric duplications by ultrasonography and computed tomography. Although it is feasible to diagnose this entity preoperatively, it is important to recognize the features of intestinal obstruction induced by enteric duplication.
A boy weighing 3,740 g was born at 42 weeks and 2 days of gestation. An abnormal structure was found in the umbilical cord at birth, and he was transported to our hospital. The structure was 2 cm in diameter and dark red. It adhered tightly to the umbilical cord and it was difficult to return into the abdominal cavity. In addition, echo and MRI examination could not confirm the continuity of the structure with the abdominal cavity. On the 4th day after birth, we incised the amnion of the umbilical cord at the bedside, and meconium was discharged from the structure. The continuity of the structure with the abdominal cavity could not be confirmed intraoperatively. At the age of 6 days, we diagnosed the patient as having vitelline duct remnants in the umbilical cord, and surgery was performed. We incised the upper abdomen, and found that the structure inside the umbilical cord was the blind end of Meckel’s diverticulum. The umbilical ring was already closed, so the intestinal tract inside the umbilical cord was in an isolated state. By opening the umbilical rings and piercing the intestinal tract, we performed wedge resection of Meckel’s diverticulum and navel plasty. Since this case was rare and not found in the representative classification of vitelline duct remnants, we herein describe our experience and similar cases.
The patient was a 14-year-old boy who liked to eat salmon sashimi, enjoying it daily. He had sudden onset right abdominal pain and visited the pediatric Emergency Care Center at our institution. Muscular defense and rebound pain were confirmed on the right side of the abdomen on physical examination. A blood examination revealed an elevated white blood cell count and the presence of hepatobiliary enzymes. Abdominal enhanced computed tomography showed a slightly high density of ascites around the gallbladder and right lower quadrant. No gallstone or biliary dilatation was recognized. Laparoscopic exploration revealed clear yellowish biliary ascites and yellow degeneration of the neck of the gallbladder serosa without perforation. We did not perform cholecystectomy but instead lavaged the abdominal cavity and inserted drains with tips placed inferior to the liver and Douglas pouch. After the operation, the patient’s systemic condition improved promptly, and his abdominal pain almost disappeared one day after the surgery. The contents of the drain also shifted to serous ascites. A microscopic examination of the feces revealed a large number of parasitic eggs diagnosed on the basis of their shape as Diphyllobothrium nihonkaiense. The patient took Praziquantel and excreted a tapeworm the next day. There was no relapse of abdominal symptoms, and the patient was discharged on the 14th postoperative day. Biliary peritonitis without perforation coexisting with tapeworm infection is extremely rare.
A male neonate was born by emergency caesarean section because of chorioamnionitis at 39 weeks of gestation. A cystic lesion was found in the left thoracic cavity by fetal ultrasound at 33 weeks of gestation. MRI showed a cystic mass of 66 × 26 × 24 mm size from the left cervix to the anterior mediastinum after birth, and a nasogastric tube was placed to prevent infection and cyst enlargement. Esophagography revealed contrast agent flow into the tract on the pyriform sinus. We diagnosed the patient as having left pyriform sinus fistula and performed pyriform fistro-cystectomy at the age of 36 days. He was discharged 19 days after the operation without sequela except for transient hoarseness. The hoarseness spontaneously resolved about 1 month after the surgery. In this case of a giant pyriform sinus fistula, infection was prevented by tube feeding and the fistula was successfully removed by elective surgery.
We report the cases of three male children diagnosed as having Crohn’s disease (CD) with perianal lesions as the initial complaint presented. The patients were 8, 11, and 10 years old and, prior to visiting our hospital, had received treatment for perianal lesions at other clinics for 2 years, 2 months, and 6 months, respectively, but with no improvement. Although they had no abdominal symptoms, endoscopic examinations were performed under general anesthesia with suspicion of CD because their blood tests showed anemia, leukocytosis, and elevated CRP levels. The endoscopic examinations revealed aphthous ulcers in their small and large intestines and hence were diagnosed as having small/large-intestine-type CD. Moreover, the weights of two of the patients showed a downward deviation in the growth chart. Perianal lesions may be manifested in CD patients prior to abdominal symptoms. When examining children with perianal lesions and/or poor weight–height gain, further investigation with endoscopy is necessary to check for the possibility of CD.
Although some authors report the usefulness of a pleuroperitoneal shunt for children, the surgical procedure of shunt implantation has not been established yet because of the size of shunt. A pleuroperitoneal shunt was implanted in a 4-year-old girl with idiopathic pleural effusion. She had chylothorax and chyloperitoneum during her neonatal period. The effusion was eliminated using a medium-chain triglyceride (MCT) formula. Then, after 4 years, dyspnea suddenly appeared. Intubation and thorax drainage were required for severe right pleural effusion. The effusion was transudative, but diuretic administration and drainage were ineffective. Lymphoscintigraphy showed a normal lymphatic system from the chyle cistern to the thoracic duct and venous angle. This means that pleural effusion can effectively pass through the lymphatic system from the peritoneum. After the implantation of the pleuroperitoneal shunt, she became free from thoracic drainage. The shunt implantation procedure is relatively easy and especially useful for transudative pleural effusion. We report this case with reference to some reports in the literature.
Kaposiform hemangioendothelioma (KHE) is classified as an intermediate malignancy and sometimes causes Kasabach–Merritt syndrome. The lesion in the intestinal tract has only been described in a few reports. We experienced treating a case of KHE, which located in the descending colon. A 5-month-old boy presented with bloody stool and his laboratory exams showed progressive anemia for 3 months. Thus, he was referred to our hospital. Colonoscopy revealed an elevated lesion with erosions and exposed vessels in his descending colon. Because conservative therapy failed and submucosal neoplasm was suspected, operative therapy was carried out. A single-hole laparoscopic-assisted surgery was performed. The descending colon was extracted and wedge resection of the lesion was performed. His postoperative course was stable, and he was discharged 7 POD. Because of the high frequency of recurrence of KHE, careful follow up is required.