Purpose: In this study, we aimed to assess our surgical indication for retractile testis on the basis of the presence or absence of testicular growth after orchiopexy.
Methods: From December 2006 to June 2018, a total of 465 patients were diagnosed as having bilateral retractile testes in our department, and we measured the large diameter of testis every 3 to 6 months by ultrasound sonography (US). We classified them as follows: Group A: unilateral disorder, Group B: bilateral disorder, Group C: ascending testis. There were 145 patients (65 in group A, 56 in group B, and 24 in group C) in whom orchiopexy was performed. Every 3 to 12 months after the surgery, we restarted measuring the testicular large diameter by US. Twenty-six patients in group A and 48 in group B were followed up.
Result: In group A, 25 of the 26 patients (96%) showed testicular growth, and the difference between the left and right testes disappeared after the surgery. In group B, 36 of the 48 patients (75%) showed growth of bilateral testes 12 months after the surgery. The remaining 12 patients showed no postoperative development, and more than 12 months after surgery, we found that 7 of these 12 patients had a higher age of first visit than those in whom development was observed, and the testicle size was about 3.3 mm smaller than the standard size.
Conclusion: In Group A, the surgical adaptation criteria of our hospital were considered to be appropriate. In group B, the testicle size at the first visit was 3 mm or more smaller than the standard size; therefore, we thought that we should operate earlier.
Purpose: The treatment outcomes of patients with laparoscopic surgery for biliary atresia (laparoscopic portoenterostomy) were retrospectively evaluated to determine whether to limit the laparoscopic surgery for biliary atresia to fully experienced surgeons.
Methods: We included 37 patients with laparoscopic portoenterostomy for biliary atresia at our institution from 2014 to 2018. Twelve patients were treated by a surgeon fully experienced in laparoscopic portoenterostomy (Group A) and 23 patients were treated by other surgeons (Group B). Jaundice reduction and jaundice-free survival of patients with the native liver in the two groups were compared.
Results: Differences in age at the time of surgery, body weight, perioperative blood loss, time of drain removal, and time that milk or formula feeding resumed in both groups were not significant. The duration of surgery was significantly shorter in Group A than in Group B. The jaundice-free survival rates of patients with the native liver were 58.3% in Group A and 60.9% in Group B at 6 months after surgery, 66.7% in Group A and 65.2% in Group B at 1 year after surgery, and 58.3% in Group A and 56.5% in Group B at 2 years after surgery. No significant difference was observed.
Conclusions: In this study, no significant difference in the rate of jaundice-free survival of patients with the native liver depending on the amount of surgical experience was observed under the guidance of an operator who was skilled in laparoscopic portoenterostomy.
Purpose: Sutureless enterostomy was invented to prevent stoma-related complications in extremely low birthweight neonates; however, its efficacy remains unknown. In this study, we aimed to evaluate the usefulness of sutureless enterostomy.
Methods: We retrospectively examined neonates (weighing less than 1 kg within 10 days after birth) who underwent enterostomy between 2015/1/1 and 2018/12/31. The early and late periods were defined as the first 30 days postoperation and over 30 days, respectively.
Results: Four patients (5 cases) underwent sutureless enterostomy (Sutureless), whereas five patients (5 cases) underwent conventional enterostomy (Conventional). The median gestational age, birth weight, age at operation, duration of operation, and blood loss volume for the Sutureless group were 24 weeks and 3 days, 605 g, 5 days, 91 min, and 3.0 ml, and those for the Conventional group were 24 weeks and 1 day, 632 g, 7 days, 95 min, and 22.0 ml, respectively. The Sutureless group had two postoperative complications (two cases and one case in the early and late periods, respectively), whereas the Conventional group had four (two cases and three cases in the early and late periods, respectively). Two patients in the Sutureless group required emergency operations owing to stoma-related complications in the late period, whereas in the Conventional group, one patient in the early period and one patient in the late period required emergency operation.
Conclusions: Sutureless enterostomy may be associated with reduced bleeding volume and stoma-related complications in the early period and with more emergency operations in the late period. Further research on stoma closure timing may be warranted.
Purpose: We have established microsurgical varicocelectomy techniques with which the testicular artery and lymphatic vessels are identified with a micro-Doppler probe and indigo carmine solution, respectively. In this study, we evaluated the results of microsurgical varicocelectomy in children and adolescents at our institution.
Methods: We performed a retrospective chart review of all patients who underwent microsurgical varicocelectomy for varicoceles during a period of 7 years and 5 months at our institution. We excluded patients who underwent bilateral varicocelectomy, simultaneous surgery for other diseases, and previous groin surgery as well as patients with <3 months of postoperative follow-up and mechanical failure.
Results: We evaluated 36 children and adolescents with left varicoceles who underwent microsurgical varicocelectomy. The patients’ median age was 12 years (range, 10–16 years), and the varicocele classification was Grade 2 in 6 patients and Grade 3 in 30 patients. The approach was subinguinal in 16 patients and inguinal in 20 patients. The average operation time was 132.5 minutes (range, 83–209 minutes). Only one patient (2.8%) developed a recurrent varicocele and underwent reoperation. None of the patients developed postoperative testicular atrophy or a hydrocele on the affected side. Twelve of the 20 patients (60%) with testicular atrophy on the affected side exhibited catch-up growth.
Conclusions: Microsurgical inguinal or subinguinal varicocelectomy is less invasive than other surgical procedures and is a familiar approach for pediatric surgeons and pediatric urologists. Because of its high safety and curability, we recommend microsurgical varicocelectomy on the affected side for children and adolescents with symptoms or testicular atrophy.
Purpose: To compare the neurodevelopmental outcomes at 6 years of age of very low birth weight (VLBW) children who underwent surgical procedures during the neonatal period with those who did not and to evaluate the long-term prognosis across the period from 2005 to 2008.
Methods: Fifteen VLBW children who had undergone neonatal surgery (surgical group) were enrolled in this study and compared with 74 who did not (nonsurgical group).
Results: The average intelligence quotient at 6 years of age was lower in the surgical group (72.7, 54–103) than in the nonsurgical group (88.8, 40–131) (p = 0.0024). We further divided the surgical group into the patent ductus arteriosus surgical group and the abdominal surgical group. There was no significant difference between the two groups with respect to the intelligence quotient at 6 years of age (p = 0.31).
Conclusions: Neonatal surgical stress may worsen the long-term neurodevelopmental prognosis of VLBW children.
The patient was a 12-year-old female who presented with abdominal pain. She was referred to our hospital with diagnoses of congenital biliary dilation and acute pancreatitis. MRCP revealed double common bile ducts. The dilated common bile duct bifurcated into the right and left hepatic ducts and joined the main pancreatic duct. Another nondilated extrahepatic bile duct was found, bifurcating into the cystic duct and opening to the major duodenal papilla. ERCP revealed that two extrahepatic bile ducts were communicating immediately below the confluence of the left and right hepatic ducts, and the dilated extrahepatic bile duct joined the pancreatic duct to form a long common duct. The patient was diagnosed as having double common bile duct with pancreaticobiliary maljunction, and resection of extrahepatic bile ducts, including the accessary common bile duct, and hepatojejunostomy were performed. The proximal extrahepatic bile duct was dissected immediately below the confluence of the right and left hepatic ducts, and the distal bile extrahepatic ducts could be separated into two extrahepatic bile ducts and dissected at the intrapancreatic level. The double common bile duct is an extremely rare biliary malformation with only 97 cases, and only 11 pediatric cases, were reported in Japan. The high incidence of pancreaticobiliary maljunctinon in children is clinically important, and a malignant tumor developed in some adult patients. Complicated bile duct conditions may cause various comorbidities. Therefore, it is important to sufficiently and accurately evaluate the bile duct system and comorbidities, and to plan an appropriate treatment strategy.
Neonatal gastric rupture has become rare in recent years, but we encountered a total of five incidents in four cases during a single year. In this study, we reviewed each incident and considered the related pathogenetic factors reported in the literature in order to apply them to future neonatal management. All the patients were premature infants born by emergent Caesarean section. They developed gastric rupture at the greater curvature side (n = 3) or at the anterior wall of the gastric body (n = 2) early after birth. The ruptures occurred in anatomically vulnerable areas characteristic of the stomach wall in newborns. In our cases, the etiologies were considered as follows: in addition to an impaired blood flow in the gastric wall due to physiological diving reflex induced by perinatal hypoxia events, an increased intragastric pressure that exceeded the tolerable upper limit of the neonatal stomach due to obstruction of the gastrointestinal passage by a meconium plug; functional hypoperistalsis of the gastrointestinal tract induced by hypothyroidism; and an organo-axial gastric volvulus peculiar to newborns. We reconfirmed the significance of careful monitoring of the abdominal findings over time and maintaining an appropriate decompression of the upper gastrointestinal tract as needed. These managements are quite common in the neonatal intensive care unit, but are important as preventive measures for the onset of neonatal gastric rupture.
With advances in high-resolution computed tomography (CT), small, sub-centimeter pulmonary nodules frequently require resection of the lesion for diagnosis and treatment. Preoperative localization of pulmonary nodules is sometimes necessary when the target nodule is too small or too far from the pleural surface to be detected intraoperatively by inspection or palpitation by surgeons. We marked small lesions with an injecting dye by CT fluoroscopy for the preoperative localization of metastatic pulmonary lesions of hepatoblastoma and combined this procedure with intraoperative indocyanine green (ICG) fluorescent imaging to identify small viable lesions. We herein report three cases of resection of minute pulmonary nodules preoperatively localized by CT-guided dye marking. Case 1: A 4-year-old boy with hepatoblastoma in the right lobe (PRETEXT II) underwent right hepatectomy. After chemotherapy, a pulmonary metastatic nodule was observed. Pulmonary wedge resection was performed via video-assisted thoracoscopic surgery on the basis of preoperative CT-guided dye marking. Case 2: A 1-year-old male infant with hepatoblastoma (PRETEXT III, V, R, M) was scheduled to undergo liver transplantation. To remove two extrahepatic metastatic lesions before transplantation, pulmonary wedge resection of the right lung was performed on the basis of preoperative CT-guided marking combined with ICG fluorescent imaging. Case 3: A 3-year-old boy with hepatoblastoma (PRETEXT III, E, R, M) in the left lobe underwent left hepatectomy. After postoperative chemotherapy, seven residual nodules in the lungs were resected on the basis of CT-guided marking and ICG fluorescent imaging findings. CT-guided marking, especially combined with ICG fluorescent imaging, is feasible and useful for identifying small metastatic pulmonary lesions of hepatoblastoma.
An 11-year-old girl who suffered from fever, abdominal pain, and the presence of a sudden upper abdominal mass was referred to our institution. After several examinations, the diagnosis of a large intraabdominal lymphangioma with intrahepatic bile duct dilatation was suspected, and it was located in the ligamentum hepatoduodenale. Since conservative treatment did not reduce the lesion size, percutaneous cyst drainage was performed on the third day of hospitalization. A CT examination after achieving a reduction in the lesion size revealed a liver cyst. Laparoscopic fenestration was performed seven days after admission. A vessel-sealing system was used to open the cyst wall to prevent any postoperative bleeding and bile leakage. She was discharged on the fifth postoperative day without any complications and has been doing well for three months after the operation without any recurrence. If a malignant tumor can be ruled out for a pediatric giant liver cyst, then it is desirable to perform preoperative drainage in order to make an accurate diagnosis, provide symptom relief, and thereafter perform surgery.
The patient was a 7-year-old boy. After being diagnosed as having acute pancreatitis, he was referred to our hospital after developing acute pancreatitis at 7 years of age and, at that time, was diagnosed as having duodenal duplication. The attending physician planned to perform endoscopic treatment, which is less invasive than surgical resection because he was a child. The cyst was incised and an ERBD tube was put in place to drain it. He thereafter regularly visited the outpatient clinic. However, three years later, he was again referred to our department after being diagnosed as having bowel obstruction. Abdominal CT revealed a drainage tube in the intestinal tract at the terminal ileum, which was the origin of the obstruction, and emergency laparotomy was thus performed. The surgical findings revealed an enterolith and a piece of a drainage tube in the intestine at the origin of the obstruction, and a diagnosis of intestinal obstruction due to a stent–stone complex was thus made. The intestine was incised and the drainage tube and enteric stone were both successfully removed to release the obstruction. Duodenal duplication is extremely rare, and there are few reports of endoscopic treatment for pediatric cases, and reports of pediatric cases of SSC are also extremely rare. Also, there are few reports of adult cases of SSC, and this is the first report of a pediatric case in Japan. In this case, we describe our findings and also discuss the course of the diagnosis and treatment, as well as report on the clinical course of bowel obstruction as a complication.
The Kasai procedure has been performed considerably for a long time, but the way to stop bleeding from the porta hepatis is different among children’s hospitals in Japan. Using hemostatic agents is one of the options to stop bleeding; thus, we used microporous polysaccharide hemispheres (MPHs) for a 1-month-old girl with biliary atresia. Although we used only MPHs for the bleeding from the porta hepatis, we did not need any other ways to stop the bleeding nor blood transfusion. Her postoperation jaundice was improved smoothly. We consider that using MPHs for the bleeding from the porta hepatis is one of the ways to stop bleeding.
We report an extremely rare case of a patient who developed shock symptoms caused by fecal impaction due to chronic constipation, who was successfully treated by emergency surgery. The patient was a 14-year-old boy who was referred to the emergency room of a regional hospital owing to vomiting, tachycardia, and hypotension due to increased abdominal distension. The patient had experienced constipation since he was a child, and had sometimes undergone enema treatment and disimpaction at a local clinic. It was judged that the patient had developed abdominal compartment syndrome due to fecal impaction, and he underwent disimpaction under general anesthesia. However, it had no effect. Therefore, we performed emergent laparotomy, removed the feces after making a sigmoid incision, and created a sigmoid colostomy. Considering the possibility of Hirchsprung’s disease, we obtained a biopsy specimen from the rectal mucosa and performed anorectal manometry. However, the results were negative. Thereafter, the rectal pelvic ratio, rectal sensory threshold, and maximum tolerated capacity were periodically measured by abdominal X-ray and enema examination, and an improving trend was observed. The colostomy was closed 21 months after the first surgery after confirming that the megacolon was shrinking. At the time of this writing, three years have passed since the stoma was closed and the patient’s bowel movements have been excellent with occasional use of only oral laxatives.
Epigastric heteropagus twins are asymmetric conjoined twins in which the parasite is attached to the epigastrium of the autosite. In epigastric heteropagus twins, the intestine originating from the parasite might exist in the omphalocele of the autosite or join to the intestine of the autosite, which could increase the risk of surgical complications. Here, we report the case of full-term epigastric heteropagus twins in which the autosite had an omphalocele and the parasite had a well-developed left lower limb and pelvis. Contrast-enhanced computed tomography revealed a vascular supply from the inferior phrenic artery of the autosite to a cyst within the omphalocele as well as the parasite. On the 5th day of life, primary closure of the omphalocele was successfully performed after an independent loop of the intestine with both ends blind within the sac of the omphalocele was excised. On the 21st day of life, the parasite including its developed phallus and scrotum, an abdominal testis, a single kidney with ureter, and a bladder filled with urine was separated. On the 32nd day of life, the patient was discharged following an unremarkable postoperative course. A comprehensive review of this rare entity including data from English and Japanese literature is presented.
A 5-year-old girl complained of abdominal pain for four days and an inflamed retroperitoneal cyst was detected posterior to the pancreas on computed tomography. We conducted empiric antibiotic therapy and the symptom was improved. The retroperitoneal cyst became smaller with a thick capsule, and ultrasonography, computed tomography, and magnetic resonance imaging revealed a solitary benign cystic lesion. We performed interval laparoscopic surgery for the retroperitoneal cyst without complications five months after the resolution of inflammation in order to confirm the diagnosis and to prevent recurrence of the symptom. A histopathological evaluation established the diagnosis of bronchogenic cyst. Bronchogenic cysts frequently occur in the mediastinum but rarely in the retroperitoneal space. Bronchogenic cysts are assumed to increase in size with age and their malignant transformations are reported in few cases. In recent years, laparoscopic surgeries for retroperitoneal bronchogenic cysts have been performed in adults and infrequently in children. We resected the retroperitoneal bronchogenic cyst completely by laparoscopic surgery despite adhesions caused by inflammation.
The patient was an 11-year-old girl. Although her mild abdominal pain was recognized one week before her first visit, it was only closely monitored and followed up. Since the abdominal pain became worse one day before her urgent hospital visit, she had a medical examination at our hospital. At the time of consultation, low-grade fever and marked tenderness from the right flank to the right upper quadrant were recognized, and peritoneal irritation was mild. Abdominal ultrasonography was performed with the suspicion of acute appendicitis and mesenteric lymphadenitis. Although the appendix and lymph nodes were not enlarged, a low-echoic mass with an unclear boundary was found in the right upper quadrant. Abdominal CT scan revealed a whirl sign in the omental fat tissue weaving, and it was diagnosed as greater omental torsion. The abdominal pain gradually worsened, and walking became difficult. Thus, single-incision laparoscopic surgery was carried out on the same day. The operative findings were torsion of the greater omentum in the right upper quadrant and necrosis of the twisted omentum. The necrotic omentum was extracted through the umbilicus and excised. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Preoperative diagnosis is possible for pediatric idiopathic omental torsion, and single-incision laparoscopic surgery is regarded as a less invasive and useful therapy.
A 7-month-old boy had repeated convulsions with hypoglycemia and hyperinsulinemia since 4 months of age, and he was referred to our hospital on the suspicion of congenital hyperinsulinism (CHI). We diagnosed him as having focal CHI in the tail of the pancreas, on the basis of the accumulation of PET and the presence of a paternal single allele mutation in the ATP-dependent K-channel gene. Owing to his resistance to medical treatment, a laparoscopically assisted partial distal pancreatectomy was performed. The lesion was identified by laparoscopic observation and palpation through a small laparotomy. As continuous octreotide subcutaneous injection was not required immediately after resection without hypoglycemia, we judged that a complete resection was achieved. Histopathological analysis showed hyperplasia of pancreatic endocrine cells. Postoperatively, medication and carbohydrate load were no longer required to maintain blood glucose, and he was discharged from the hospital on postoperative day 9. Continuous glucose monitoring in the first month postoperatively showed no hypoglycemia, and the patient’s follow-up was terminated. Focal-type CHI can be treated by surgery with early relief of symptoms without sequelae. In this patient, we effectively used laparoscopy to identify a small and superficial lesion and performed a complete resection through a small laparotomy less invasively.
A 10-year-old girl was admitted to our institute owing to vomiting and abdominal pain. A mass was palpated in the upper abdomen. She had trichotillomania and trichophagia, and thus a trichobezoar was suspected. A CT scan revealed a huge mass with air bubbles, and an upper gastrointestinal endoscopy revealed a trichobezoar in the stomach. Because its removal was difficult endoscopically, an operation was performed. A small laparotomy was placed in the umbilicus, and a 3-cm incision was made in the stomach wall, and an ALEXIS® Wound Retractor XS was inserted into the stomach. A trichobezoar was removed under direct view. The weight of the trichobezoar was 290 g, which was removed in 110 minutes. No remnant was found in the stomach endoscopically by the glove method. By inserting a wound retractor into the stomach, we were able to remove the trichobezoar under direct view, with minimum umbilical incision. The intragastric endoscopic technique by the glove method is simple and useful to cover an approach by a small laparotomy.
We report a case of accessory hepatic lobe torsion accompanied gallbladder torsion. A 14-year-old boy was admitted to our hospital after surgery for cloacal exstrophy. He was transported to our hospital with sudden upper abdominal pain. Computed tomography scans revealed dilatation of the gallbladder and swelling of the wall. Moreover, a low-density mass existed in contact with the gallbladder. We suspected gallbladder torsion and omental torsion on the basis of image findings. Thus, we performed emergency surgery. We decided to perform a laparotomy with a right oblique incision because he had a history of ileal colostomy on his right abdomen and part of the urinary tract was on his left abdomen. We found a congestive liver and an enlarged gallbladder under the wound. We diagnosed him as having accessory hepatic lobe torsion and gallbladder torsion. The congestion was improved after the torsion was released. The accessory hepatic lobe and gallbladder were removed because of possible recurrence. His postoperative course was good, and he was discharged on the fifth day after the operation. Reports of twisting of the accessory liver lobe and gallbladder are rare. If the gallbladder torsion is suspected on the basis of CT images and a mass is found near the gallbladder, we should consider the presence of accessory hepatic torsion. Moreover, because all cases of twisted accessory hepatic lobe and gallbladder have a history of abdominal wall surgery, it may be necessary to keep in mind the accessory hepatic lobe during anterior abdominal wall surgery.
A six-year-old boy was admitted to a family hospital owing to fever, vomiting, diarrhea, and abdominal pain. He was diagnosed as having acute gastroenteritis and treated, but he showed no improvement. He was referred to our department because a marked inflammation and a pelvic abscess were confirmed by abdominal CT. Lower abdominal pain accompanied by peritoneal irritation was observed, and a diagnosis of a pelvic abscess with perforated appendicitis was made on the basis of the CT findings. Because his general condition was maintained, conservative treatment was selected, and endoscopic transrectal drainage was performed on the 9th day after onset because the pelvic abscess was in contact with the rectal wall. The fever disappeared the next day, and abdominal CT on the 12th day after surgery showed that the abscess cavity had almost disappeared, and he was discharged 14 days after surgery. On the 19th day after surgery, part of the stent escaped from the anal margin and was removed endoscopically. There was no recurrence after removal, and laparoscopic appendectomy was performed 3 months later. Although this method has not been reported for children, it is considered to be a minimally invasive and safe procedure in this case, and it may be a useful treatment option.
Cases of vaginal foreign body is rare in children. We herein report two cases of vaginal foreign body. [Case 1] An eleven-year-old girl, who had complained of a foul-smelling brown vaginal discharge for 10 months, was referred to a former hospital owing to severe right lower abdominal pain. Computed tomography showed a vaginal foreign body, and she was transferred to our hospital. Ultrasonography and magnetic resonance imaging revealed the possibility of strangulation of the uterine cervix. Emergent removal of the foreign body was performed under general anesthesia. Although the uterine cervix was incarcerated into the cylindrical foreign body, the color of the cervix was improved following the removal of the foreign body. The symptoms were relieved immediately after operation. The child abuse committee concluded that the possibility of sexual abuse was low, and she was referred to a pediatric psychosomatic physician during hospitalization. It was unclear how the foreign body was inserted. [Case 2] A thirteen-year-old girl was referred to our hospital without any specific symptoms owing to a vaginal foreign body that she inserted herself. Ultrasonography and computed tomography showed a vaginal foreign body that was successfully removed under general anesthesia.