Purpose: We have been actively carrying out transcatheter arterial embolization (AE) in children suffering from traumatic splenic injury associated with extravasation and pseudoaneurysms. Many patients could be successfully managed with conservative treatment by AE.
Method: From January 2001 to December 2016, 13 patients aged younger than 15 years were transferred to the emergency room of our institute because of traumatic splenic injury. They comprised eight boys and five girls, and their median age was 9 years (age range: 3–14 years). Eight patients had only splenic injury, and the rest had multiple organ injuries. Their clinical data were investigated.
Results: On the basis of the 2008 diagnostic criteria by the Japanese Association for Surgery of Trauma, the severity of one patient was categorized into Ib, four patients into IIIa, and eight patients into IIIb. Three patients (IIIb) required laparotomy. Six patients underwent angiography; three of them (extravasation, 2; pseudoaneurysm, 1) were treated by AE. In all the patients, bleeding was successfully controlled and managed conservatively except for those who required laparotomy.
Conclusion: Even when patients have splenic injuries with extravasation and pseudoaneurysms, AE enables the control of bleeding and the treatment of patients without surgery.
Purpose: Congenital esophageal stenosis (CES) is a rare condition, and its standard treatment has not been completely established. The purpose of this study was to clarify the surgical indications for this disease.
Methods: Data of six patients with CES treated at our hospital from 2007 to 2017 were reviewed retrospectively. The patients were classified into the balloon dilatation only group (DG, n = 3 patients) and the surgery group (SG, n = 3 patients).
Results: The median onset age was 4 months (range: 0–28 months). All patients were diagnosed on the basis of esophagograms and underwent balloon dilatation. The average wedge ratios (WRs) of the balloon’s maximal and minimal diameters were 0.95 (0.82–1) and 0.68 (0.52–0.78) in DG and SG, respectively. The stenosis exacerbated after dilatation in one patient in DG and all patients in SG. The patient in DG was the most difficult to treat. In DG, dilatation was performed six times on average (4–10 times). In SG, the preoperative dilatation was performed six times on average (5–7 times), and all patients underwent resection of the stenotic site and end-to-end anastomosis. The pathological finding was only tracheobronchial remnant and none of the patients required postoperative dilatation. The postoperative course in both groups was uneventful.
Conclusion: WR and the presence of exacerbation of stenosis after dilatation could be the useful surgical indications for CES.
Adhesive small bowel obstruction is a relatively rare surgical complication after liver transplantation. We report on a case of adhesive small bowel obstruction at the dissected plane of a liver graft. An 8-year-old girl was admitted to our hospital for abdominal pain and diagnosed as having a postoperative adhesive bowel obstruction. The patient had undergone living donor liver transplantation to treat citrullinemia at age 6. She was initially treated conservatively using an ileus tube; however, the bowel obstruction recurred when oral intake resumed. The patient’s abdominal Computed tomography images showed that the dilated small bowel was obstructed by an adhesive band in the right upper quadrant. Emergency laparotomy was performed, and we observed a strong adhesion of that to the colon and abdominal wall. There was also marked adhesion of the small bowel to the dissected plane of the liver graft. Adhesiolysis and partial resection of the small bowel were performed. Her postoperative course was uneventful. She was discharged on postoperative day 14. Massive small bowel adhesion to the dissection plane of the liver graft can cause severe surgical complications after partial liver transplantation. To avoid re-laparotomy due to adhesive small bowel obstruction, it is necessary to apply adhesion barrier agents to the small bowel and to the dissected plane of the liver graft.
Phyllodes tumour most commonly occurs at the age of 40 and above, accounting for <1% of all breast tumour cases. Thus, there are only a few reported cases of phyllodes tumour in children. Here, we report a paediatric case of recurrent bilateral phyllodes with a discussion of the literature. A 14-year-old girl with no family history of carcinoma, albeit with a history of liver tumour excision at the age of 5 years and tonsillectomy at the age of 8 years, presented to us with a mass on her right breast and was referred to Toho University Omori Hospital. Upon admission, a 4-cm elastic soft tumour was palpated at the outside upper portion of her right breast. On ultrasonography, the tumour appeared well-defined, lobulated, and partially nonhomogeneous from the inside and with multiple small cysts in the solid mass. Lumpectomy was performed. Histopathological examinations revealed benign phyllodes tumour, and its excised margin was negative for tumour cells. About 16 months after the first excision, a new breast mass appeared on both sides, and the mass was excised again. Histopathological examinations revealed benign phyllodes tumour. Since the first surgery, four recurrences occurred and lumpectomy was performed four times. Phyllodes tumour tends to occur multiple times, and approximately 3 to 10% of such cases recur even when the tumour is benign; therefore, a careful follow-up of patients with this tumour is necessary.
A 21-year-old man with severe motor and intellectual disabilities associated with chromosomal abnormalities was admitted to our hospital and underwent laryngotracheal separation for dysphagia. The postoperative course was uneventful except for fever of unknown origin, and he was discharged on postoperative day 13. However, he complained of abdominal pain the day after discharge. He was readmitted to our hospital because of a high serum amylase level and abdominal dilatation revealed by abdominal computed tomography. On the basis of medical history and test results, he was diagnosed as having acute pancreatitis due to superior mesenteric artery (SMA) syndrome. Although acute pancreatitis due to SMA syndrome is extremely rare and often requires surgical treatment, drainage with strict posture management has been shown to be successful. Children with severe motor and intellectual disabilities often develop problems that require surgery at an early age, and a pediatric surgeon often follows up these patients, even after the transitional period. If a patient with severe motor and intellectual disabilities presents with biliary vomiting or abdominal pain, SMA syndrome or acute pancreatitis due to SMA syndrome should be considered in the differential diagnosis and treated as early as possible.
A 17-day-old boy admitted to our hospital with complaint of frequent nonbilious vomiting and weight loss, and diagnosed with hypertrophic pyloric stenosis (HPS). On the night of admission, the vomited matter had become bilious; however, an ultrasonography showed no findings that indicated intestinal malrotation. An atropine therapy stopped the bilious vomiting; however, the bilious vomiting reappeared a few weeks later. An upper gastrointestinal series showed a pyloric string sign and regurgitation of the contrast medium to the stomach. On the basis of these findings, he was diagnosed as having HPS complicated by postpapillary duodenal obstruction. Laparotomy showed an anomalous membranous ligament between the posterior side of the transverse colon and the retroperitoneum caudal to the gallbladder. After dividing the ligament induced extrinsic distal duodenal obstruction, Ramstedt’s procedure was performed. Intraoperative duodenography showed no obstruction. His postoperative clinical course was uneventful. The HPS in our case showed an atypical symptom, that is, bilious vomiting with extrinsic distal duodenal obstruction caused of an anomalous ligament.
We report a case of a 0-day-old female neonate, whose mother’s pregnancy was determined in early gestation. Her mother had not visited a doctor since then and had not received prenatal care. She was delivered at home by vaginal delivery at 36 weeks and 6 days of gestation. The mother and neonate were both transferred to our emergency room because the neonate had gastroschisis with prolapse of the intestinal tract and bilateral oviducts. We performed silo placement on day 1, and the prolapsed organs gradually regressed into the abdominal cavity. The abdominal wall defect was covered with the umbilical cord on day 10, and the umbilical cord fell off on day 47. She was discharged on day 78 after the surgery with no serious complications such as sepsis. Neonates delivered from mothers without prenatal care have a poor prognosis. However, in cases such as gastroschisis with minor complications, if the care after birth is appropriate, the patient could be saved even if delivered at home. It is obvious that delivery from mothers without prenatal care involves high risk. From the characteristics of the mother, it is possible that in the future she will become pregnant again without prenatal care and deliver another infant with gastroschisis. There is an urgent need to develop a system to educate not only mothers but also fathers on the importance of prenatal care and fetal diagnosis.
We examined a low-birth-weight 1-day-old male neonate by abdominal contrast-enhanced computed tomography (CT), which revealed splenic damage (IIIb). Conservative treatment was successful in this patient. His mother experienced premature labor and labor pains at 27 weeks and 5 days of gestation, and urgently gave birth through Cesarean section. There was no difficulty in the delivery of the infant. His birth weight was 1,085 g, and his Apgar score was 8/7. He developed respiratory distress syndrome. Artificial respiration was used, and the patient was managed via intratracheal intubation 8 min after birth. He experienced entire-body pallor 16 h after birth, accompanied by abdominal swelling. The level of hemoglobin was 5.7 g/dl. Abdominal ultrasonography revealed abdominal dropsy and a hematoma in the splenic hilum. However, we were unable to diagnose the nature of damage to the spleen. Therefore, we performed examinations by abdominal contrast-enhanced CT via the intravenous administration of iopamidol (70% of the usual quantity). The results revealed complex deep spleen injury (IIIb) without hilar vessel injury. We initiated conservative therapy through blood transfusion. For the examination of newborns by CT, the use of contrast media is not recommended. However, we can safely perform this examination by fluid infusion after inspection to avoid renal failure due to the use of contrast media. This approach allows us to obtain useful information from images obtained by CT using contrast media.
We report a case of xanthogranulomatous cholecystitis (XGC) that developed in childhood. The patient was a 13-year-old girl with a history of abdominal pain. She was diagnosed as having acute cholecystitis on the basis of her enhanced inflammatory responses and gallstone/bladder wall thickening. She was relieved temporarily by conservative treatment, but she was admitted and discharged repeatedly owing to abdominal pain after meals and referred to our hospital for further examination and treatment. At the time of admission to our hospital, she showed no signs of gallbladder inflammation but was judged as having conservative-treatment-resistant gallstones and cholecystitis; thus, laparoscopic cholecystectomy (LC) was performed. Histopathological diagnosis revealed XGC, and the development from acute cholecystitis to xanthogranulomatous formation was analyzed retrospectively. When abdominal pain recurs repeatedly in children with cholelithiasis, it is necessary to carefully monitor changes in the gallbladder wall by ultrasonography and consider early LC, given the possibility of XGC development without the enhancement of inflammatory responses.
An accessory spleen is found in 10–30% of necropsies, but is usually asymptomatic and rarely involves torsion. We experienced treating a pediatric case of accessory spleen torsion. A 7-year-old boy was admitted owing to left upper abdominal pain. Abdominal ultrasonography revealed a solid mass in the left upper quadrant. Enhanced computed tomography showed a poorly enhanced mass. Magnetic resonance imaging revealed that the mass was hypointense on T1-weighted images and isointense on T2-weighted images. With the preoperative diagnosis of abdominal tumor, we performed open surgery. The operation showed a solid tumor of 6.0 × 7.0 cm size and had a twisted pedicle. Histopathological examinations showed that the mass contained splenic tissue with hemorrhagic necrosis. The final diagnosis was torsion of an accessory spleen with infarction. It might be difficult to make a definitive diagnosis of accessory spleen torsion preoperatively.