Purpose: To examine the effectiveness of taping treatment for infantile umbilical hernia, a retrospective questionnaire survey was carried out in the pediatric surgery institutes in the Kyushu Pediatric Surgery Study Group.
Methods: Infants with umbilical hernia registered from January 2013 to December 2015 were included in this study. Their therapeutic results were assessed at the end of June 2016.
Results: Replies were obtained from 24 institutes. Cure was judged on the basis of the closure of the hernia orifice. The number of infants who underwent the taping treatment was 1,320. Cure was achieved in 908 infants, whereas no cure was found in 158 infants; 48 infants dropped out owing to skin disorders and results were not known in 206. Among the 333 infants in whom monitoring without treatment was performed, spontaneous cure was seen in 146 infants and no cure in 111 infants; results were not known in 76. The cure rate of taping treatment was significantly higher than that of monitoring without treatment (85.2% vs. 56.8%, p<0.05, χ2 test). Furthermore, the duration until cure was less than 4 months in about 80% of the infants with taping treatment, whereas the duration in many infants monitored without treatment was more than 1 year.
Conclusions: The taping treatment for infantile umbilical hernia shortened the duration until cure, but the cure rate of this treatment did not exceed the 90% spontaneous cure rate of the untreated patients at 2 years of age as described in conventional textbooks. However, the spontaneous cure rate found by our questionnaire survey was unexpectedly low. Therefore, the spontaneous cure rate of infantile umbilical hernia should be further investigated by prospective studies.
Purpose: We performed the Hassab operation on portal hypertension (PH) patients when esophagogastric varices were uncontrollable under endoscopic therapy or hypersplenism was severe resulting in thrombocytopenia. We examined the long-term results of the Hassab operation performed in our department.
Methods: A retrospective study was carried out for PH patients who received Hassab operation at our institution.
Result: We have conducted the Hassab operation on 5 patients, 2 with extrahepatic portal vein occlusion, 1 with congenital liver fibrosis, and 2 with biliary atresia after surgery. All patients needed blood transfusion preoperatively owing to the rupture of esophageal varices. The Hassab operation was performed at the ages of 3 to 10 years. In all 5 patients, pancytopenia improved immediately after the procedure and liver function was maintained. In 4 patients, mild esophageal varices required endoscopic therapy several times after the Hassab operation, were finally easily controlled. One patient died after liver transplantation for liver cirrhosis. The others are doing well for 7 to 17 years without postoperative complication.
Conclusion: For portal hypertension in childhood, the Hassab operation can be one of the effective options for some patients having refractory esophageal varices without liver dysfunction.
Purpose: The therapy for rare congenital esophageal stenosis (CES) varies according to its etiology. In this study, we aimed to determine preferable strategies in infants diagnosed as having CES.
Methods: We retrospectively reviewed the cases of 10 pediatric patients (mean age, 16 months; male, n = 9; female, n = 1) diagnosed as having CES between 2000 and 2015.
Results: Symptoms at onset comprised vomiting (n = 7), presence of foreign bodies (n = 1), and dysphagia (n = 2). All infants were assessed by esophagography, which revealed abrupt narrowing in nine and tapered narrowing in one. It was difficult to classify the preoperative diagnosis of CES by gastrofiberscopy and endoscopic ultrasonography, as well as intraesophageal manometry and 24-h pH monitoring. The etiologies were identified as membranous web formation (n = 1), tracheobronchial remnants (n = 4), fibromuscular thickening (n = 4), and bronchial gland dysfunction (n = 1). Nine patients were surgically treated by myotomy (n = 2) and segmental resection with end-to-end anastomosis (n = 7). Two of the three patients who did not improve after dilation underwent surgery. We added fundoplication in seven of nine patients with surgery. None of the patients had gastroesophageal reflex disease.
Conclusion: Determining the appropriate strategies is difficult for patients with CES. Balloon dilation often fails to provide symptomatic improvement except for MB. We advocate surgical management as a first-line strategy.
Purpose: We analyzed the efficacy of the new antiseptic solution “Olanedine® antiseptic applicator” in pediatric surgery, because to the best of our knowledge, there have been no reports about it.
Methods: Patients who were scheduled to receive surgery for inguinal hernia, undescended testis, and umbilical hernia were divided into two groups on the basis of the antiseptic used (P-Group: treated with povidone-iodine; O-Group: treated with Olanedine® antiseptic applicator). Preoperative time (from intubation to the start of surgery), incidence of infection, incidence of skin lesions, and cost were compared between the two groups.
Results: Surgeries were performed in 294 patients (P-Group: 130 patients; O-Group: 164 patients). There were no statistically significant differences in sex distribution (P-Group: 42 women, 88 men; O-Group: 45 women, 119 men), mean age (P-Group: 39.7 months; O-Group: 40.8 months), underlying disease, and incidence of infections. The average preoperative time was significantly shorter in the O-group (10 min) than in the P-group (13 min). Furthermore, the incidence of postoperative skin lesions was significantly lower in the O-Group (0 patients) than in the P-group (6 patients). The cost of treatment was lower for the O-Group than for the P-Group.
Conclusions: The new antiseptic solution Olanedine® antiseptic applicator is expected to reduce the preoperative time, the incidence of infections, and the cost of pediatric surgery.
Purpose: The aim of this study was to determine the usefulness of the Stool Color Card (SCC) for the early detection of biliary atresia (BA) and the prevention of vitamin K deficiency hemorrhage (VKDH).
Method: A retrospective chart review was conducted on 41 patients who underwent Kasai enterostomy (KPE) at our hospital from 2005 to 2018. We compared the ages at admission and KPE, and the incidence of VKDH between the early group of 27 patients before (2005–2011) and the late group of 14 patients after (2012–2018) the implementation of SCC screening. We also compared the ages at admission and KPE between 13 patients with VKDH and 28 patients without VKDH. A survey on the use of SCC by pediatricians in Hyogo Prefecture was performed.
Results: There were no significant differences between the early and late groups in terms of the ages at admission [64 (8–102) vs. 62 (0–86) days] and KPE [70 (22–111) vs. 69.5 (25–97) days], nor the incidence of VKDH (29.6% vs. 35.7%). The ages at admission and KPE were significantly later in patients with VKDH than in those without VKDH [66 (43–86) vs. 52 (0–86) days, p = 0.03; 74 (59–97) vs. 59.5 (22–111) days, p = 0.01].
87% of the survey participants considered that SCC was useful for the early detection of BA; however, 86% answered that they needed more information about SCC.
Conclusions: The usefulness of SCC for the early detection of BA might be limited, unless parents, as well as health care providers, are more informed about SCC.
A 12-year-old boy was referred to our hospital owing to left abdominal pain that lasted for two days after trauma. Contrast CT showed a 4-cm-diameter mass localized in an area inferior to the left kidney. He was admitted to our hospital with suspicion of left abdominal tumor. Ultrasonography revealed that the blood flow in the mass vanished, and enhanced MRI demonstrated a twisted cord from the mass with hemorrhagic infarction toward the splenic hilum. Therefore, he was diagnosed as having accessory spleen torsion, and laparoscopic resection was performed on the 19th day after his injury. Histopathological findings showed that the accessory spleen infarction occurred owing to pedicle torsion. Accessory spleen is very rare and the preoperative diagnosis was difficult owing to specific findings in images. From our experience, the detection of pedicle torsion is important for the preoperative diagnosis.
Intussusception in children over 5 years of age often has mechanical causes such as polyps, and it is necessary to investigate and remove the causative lesion. We experienced treating a case of an adolescent boy who had intussusception caused by a juvenile polyp in his cecum, on which we found a part showing a malignant transformation. A 7-year-old boy, who had a history of intussusception at age 5, had intermittent abdominal pain and was diagnosed as having intussusception. He was treated by noninvasive reduction successfully, but it recurred after 2 days and he was treated again. He was introduced to our institution to determine the mechanical cause in his intestine. An Ip-type polyp was recognized in his cecum by colonoscopy, and polypectomy was performed endoscopically. A histopathological examination revealed a part showing adenocarcinoma in situ on the tip of the juvenile polyp. This was a single polyp and there was no sign of metastasis. The patient was closely followed-up. It is extremely rare that a malignant transformation is found in a solitary juvenile polyp. However, this possibility has to be taken into consideration when a large polyp with a long history of intussusception is found.
There are no standardized treatment strategies for neonatal testicular torsion, which include emergency surgery or contralateral orchiopexy. We experienced treating four cases of patients with neonatal testicular torsion, including one patient suspected of having bilateral asynchronous onset. Four male infants were found to have swelling of the scrotum within 10 days of birth and underwent surgical removal or fixation of the affected-side testis by emergency operation. One patient was found to have contralateral testicular atrophy with microcalcification by a regular ultrasonography checkup at 5 years of age. In that patient, bilateral asynchronous neonatal testicular torsion was suspected. From our experience with this patient, another patient underwent intraoperative exploration and orchiopexy of the contralateral testis. Most cases of neonatal testicular torsion occur during the fetal period. Even with emergency surgical intervention, the salvage rate of the testis is extremely low. In addition, 7% of cases of neonatal testicular torsion are bilateral, and most have an asynchronous onset detected by contralateral surgical exploration. Therefore, the contralateral testis can be salvaged by emergency surgical exploration and orchiopexy. Since bilateral torsion leads to anorchia and loss of fertility, emergency contralateral exploration with orchiopexy is recommended.
We experienced treating two patients with colonic cancer diagnosed at school age and adolescence. Neither patient had a family history of cancer. [Case 1] A 14-year-old boy presented with the chief complaints of appetite loss and weight loss. He was referred to our hospital because of anemia and abdominal tumor noted on computed tomography (CT) images. Enhanced CT showed a circumferential elevated lesion in which the lumen was completely occluded along with multiple polyps. Left hemicolectomy and D2 + paraaortic lymph node dissection were performed. The resected tumor was diagnosed as adenocarcinoma, and the pathological stage was IV. Subsequently, chemotherapy was performed. However, he died one year after the operation owing to recurrence and metastasis. [Case 2] A 10-year-old boy presented with the chief complaints of bloody stool and abdominal pain. He was referred to our hospital owing to a diagnosis of intussusception based on contrast-enhanced CT findings. Emergency laparoscopic exploration was performed to assess the tumor. The tumor was suspected to be malignant lymphoma, and local excision was performed. The pathological diagnosis was mucinous carcinoma. Laparoscopic left hemicolectomy and lymph node dissection of D3 were performed similarly to the treatment of adult colon cancer. The final pathological diagnosis was stage IIIb, and chemotherapy was performed. The patient experienced no recurrence for two years after operation. [Conclusion] Colorectal cancer in children is extremely rare, but it is necessary to identify it correctly when gastrointestinal symptoms are prolonged.
A 1-day-old female infant was admitted to our hospital because of esophageal atresia. She was born weighing 3,178 g at the gestational age of 41 weeks 5 days. She was diagnosed as having type-C esophageal atresia preoperatively. On the same day, her tracheoesophageal fistula (TEF) was closed and her esophagus reconstructed. No anastomotic leakage was observed in the esophagogram taken at 11 days of age; thus, oral feeding was started. However, respiratory infection was noted. On day 18, her trachea was visualized by a videofluoroscopic examination while swallowing and TEF was confirmed. Oral feeding was discontinued, and prophylactic antibiotics were started. Bronchoscopy was performed at 33 and 39 days of age. The upper TEF was separately observed from the initial TEF treatment section, and type-D esophageal atresia was diagnosed. Upper TEF dissection was performed at 65 days of age. A guide wire was placed in the fistula. In the last follow-up, that is, 6 months postoperatively, no recurrence was observed. Comprehensive preoperative examination and preparation should be performed prior to curative surgery for type-D esophageal atresia discovered after the initial surgery.
A 14-year-old girl was referred to our hospital with a sudden onset of left abdominal pain during a physical education lesson. Chest-abdominal CT scans demonstrated a large amount of gastrointestinal gas in the left pleural cavity. She underwent an emergency laparoscopic surgery under the diagnosis of late-presenting congenital diaphragmatic hernia. A Bochdalek hernia was confirmed, in which the majority of the stomach, spleen, accessory spleen, splenic flexure of the colon, and greater omentum had prolapsed into the left pleural cavity through a hernial orifice measuring approximately 10 × 3 cm. The prolapsed organs were reduced, and the hernia orifice was closed completely by using interrupted sutures. Her postoperative course was uneventful and she was discharged on postoperative day 4. Late-presenting congenital diaphragmatic hernia is extremely rare because more than 95% of patients with congenital diaphragmatic hernia are newborns and most of the remainder are infants. Hernia usually occurs on the left side, in which herniation is often induced by an increased intraabdominal pressure during physical exercise, and patients with hernia present with abdominal symptoms rather than respiratory manifestations. An early diagnosis of hernia followed by an adequate surgical management is mandatory.
The patient was a 17-year-old male. A congenital giant cystic lesion on the neck was detected prenatally, and he was diagnosed as having cervical cystic lymphatic malformation postnatally. Two rounds of sclerotherapy were performed during infancy. The cyst size was markedly reduced. At 4 years of age, he underwent surgical removal of the excess skin at the Department of Plastic Surgery, and the swelling in the neck improved. Thereafter, he discontinued outpatient visits on his own and no follow-up was conducted. When he had a fracture of the cervical spine during baseball practice at 17 years of age, multiple cystic lesions in the bone were detected. MRI indicated no recurrence of the cervical cystic lesion but multiple cystic lesions in the cervical spine, thorax, ribs, iliac bone, and spleen were detected; thus, he was diagnosed as having generalized lymphatic anomaly (GLA). Bone union occurred later at the fracture site of the cervical spine. No pleural effusion, cardiac effusion, or ascites were noted, and blood analysis showed no abnormality. Therefore, he is currently under follow-up with no treatment. Cystic lymphangioma is currently defined as lymphatic malformation due to developmental disorders of lymphatic vessels. The present case was classified as a macrocystic-type lymphatic malformation and considered to belong to a disease group different from GLA, which is a systemic disease. However, GLA may develop during the course, as in this case, and long-term follow-up in addition to diagnosis and treatment may be warranted.
We report a case of esophageal pseudo-diverticulum. A 1-year 1-month old boy was admitted to a previous hospital with the complaints of postprandial vomiting and stridor at crying. Because an esophageal penetration was suspected by computed tomography, he was referred to our hospital. An emergency esophageal endoscopy revealed an esophageal pseudo-diverticulum caused by a piece of polyester film lodged in the mid-esophagus. His symptoms disappeared after the foreign body was removed. The esophageal diverticulum has markedly shrunk over 5 years. An esophageal foreign body risks perforation and it is necessary to remove it urgently. If there is no witness to foreign body ingestion and there are no notable symptoms, it may lodge in the esophagus for a long period and cause serious symptoms. It is necessary to add esophageal foreign body ingestion to the differential diagnosis when we observe chronic vomiting or stridor due to an unknown cause in children.