Purpose: The Nuss procedure is currently the first choice for pectus excavatum in many institutions, but there are only a few studies on the removal of Nuss bars. In this study, we retrospectively reviewed the surgical technique for the Nuss bar removal in our hospital.

Methods:

1) Subjects

Between August 2005 and December 2018 we removed Pectus bars^® (Medical U & A; hereafter, bar) of 289 patients who underwent Nuss procedure in our hospital. The patients who were difficult to continuous bar placement, simultaneous operation for other disease and over 16-years of age at the time of Nuss procedure were excluded for this study. 184 patients were included finally.

2) Surgical technique

The bars are exposed from scars on both sides and straightened with a removal gear before removal. If patients have no chest symptoms, the patient will discharge two days after surgery.

Results: The median age at surgery was 14 years. The average operation time was 60.6 minutes, and the amount of bleeding was less than 10 ml in 162 patients, 10–50 ml in 8 patients, 51–100 ml in 11 patients, and 101–500 ml in 3 patients. All patients developed no complications during the intraoperative and postoperative periods, and none of the patients required extension of hospital stay.

Conclusion: We removed 274 bars from a total of 184 patients, and the results were generally good without serious complications. We suggest that this technique is appropriate for the removal of bars after the Nuss procedure.

Purpose: We evaluate pediatric appendicitis that recurred after conservative therapy in our hospital.

Methods: In our hospital between 2014 and 2019, 135 patients with pediatric appendicitis were evaluated and grouped as follows: 96 operated patients, 28 non-operated patients, and 11 operated patients with recurrence after conservative therapy (hereafter, recurrence patients).

Results: In terms of age, there was no significant difference between these groups of patients. There was a significant difference in the count of leukocytes between the operated and non-operated patients, and between the non-operated and recurrence patients. There was a significant difference in the C-reactive protein level between the operated and non-operated patients, and between the operated and recurrence patients. The maximum diameter of breadth of the swollen appendix (mean ± standard deviation in mm) was measured by ultrasonography or computed tomography as follows: 10.7 ± 3.2 (operated patients), 5.5 ± 2.0 (non-operated patients), and 8.0 ± 2.6 (recurrence patients), and there was a significant difference between the groups.

Conclusions: The high recurrence rate after conservative therapy among patients with an enlarged appendix of 8 mm diameter or larger indicates that interval appendectomy should be considered for such patients.

We report a case of pelvic osteosarcoma successfully treated with laparoscopic spacer placement and subsequent proton beam therapy. A 7-year-old girl underwent chemotherapy for osteosarcoma arising in the right ilium and was referred to our hospital for proton beam therapy. Because the intestine adjacent to the tumor was excluded from the radiation field, we performed laparoscopic spacer placement prior to proton beam therapy. Effective displacement of the intestine was achieved by the combined use of a tissue expander and a Gore-Tex^® sheet, and proton beam therapy was safely performed without any symptoms of radiation enteritis.

A 15-year-old boy complaining of abdominal pain visited a clinic and underwent an enema for constipation. However, his symptoms did not improve, so he was referred to our hospital. Gastroenteritis was suspected, and he was hospitalized owing to a lack of any specific findings concerning his clinical symptoms and examination results. The symptoms worsened after hospitalization, and he ultimately required analgesics of not only acetaminophen but also pentazocine. Enhanced computed tomography (CT) 45 h after the onset showed a strangulated intestinal obstruction due to mesenteric hiatus hernia. He then underwent emergent laparotomy. On entering the abdominal cavity, a mesenteric defect was found with incarceration in a 90-cm segment of the necrotic distal ileum. The necrotic small intestine was resected, primary anastomosis was performed, and the mesenteric defect was closed. The postoperative course was uneventful, and he was discharged 11 days after the operation without any complications. The mesenteric hiatus hernia was difficult to diagnose preoperatively. This case was diagnosed by preoperative enhanced CT, but the patient required small bowel resection because of the delayed diagnosis. Bowel obstruction without a history of laparotomy is often difficult to diagnose. We should pay close attention to not the need for analgesic medication but also changes in the symptoms in cases of constant abdominal pain in order to prevent the need for bowel resection.

A 15-year-old girl with a one-year history of swallowing disturbance was referred to our institution. After several examinations, she was diagnosed as having esophageal achalasia. On the 14th day of hospitalization, dilatation was performed, but the outcome was poor. She was discharged on the 21st day of hospitalization after the introduction of tube feeding. After the patient’s examinations were completed, we decided on a laparoscopic Heller myotomy, but we found it difficult to wait for the patient to recover from severe psychological distress. Perioral endoscopic myotomy (POEM) was performed under general anesthesia at another institution two months after the initial treatment with the help of a gastroenterologist. During the POEM procedure, a 7-cm-long myotomy of the inner orbicularis muscle was performed through the submucosal tunnel created at the posterior wall of the esophagus. The postoperative course was uneventful, and the Eckardt score markedly decreased (from 6 to 0 points). She was discharged on the fourth postoperative day and showed an early return to normal swallowing without recurrence. In the treatment of pediatric esophageal achalasia, we should recognize that the effect of pneumatic balloon dilatation may be limited. Recently, POEM has been accepted as an effective alternative to a conventional laparoscopic approach in pediatric patients. However, regarding the actual POEM implementation for pediatric patients, close cooperation between pediatric surgeons and gastroenterologists is necessary.

The patient was an 8-year-old girl who had been suffering from chronic constipation from the age of 1 year; however, she had not visited any medical institution. At the age of 7 years, she suddenly developed abdominal pain and was diagnosed as having sigmoid volvulus (SV) on the basis of physical and diagnostic imaging findings. She underwent endoscopic detorsion under general anesthesia. On the basis of postoperative contrast enema findings, she was diagnosed as having sigma elongatum. Although attempts were made to resolve her chronic constipation with laxatives and Chinese herbal medicines, no improvement was observed. SV recurred 10 months after the first occurrence; therefore, the patient again underwent endoscopic detorsion. As SV was recurring and the patient’s chronic constipation was refractory to conservative treatment, surgical treatment was planned. When the patient was 8 years old, she underwent laparoscopic-assisted resection of 20 cm of the sigmoid colon. Postoperatively, the patient’s constipation markedly improved. As sigma elongatum causes SV and chronic constipation, which can markedly lower the quality of life, surgery appears to be a valid choice in symptomatic patients.

[Case report] A two-day-old girl who had no problems during birth was transferred to our hospital because of abdominal distension and respiration disorder. At the time of hospitalization, abdominal X-ray examination showed abdominal free air, and emergency surgery was performed for a gastro-intestinal perforation. Dirty ascites in the entire peritoneal cavity and perforation in the anterior wall of the duodenal bulb were found. After abdominal irrigation, the duodenal perforation was closed by omentum plugging. Famotidine was administered immediately after surgery and continued for 10 days. Milk feeding was started five days after surgery and she was discharged two weeks after surgery. [Discussion] Neonatal duodenal perforation is a rare disease. The most common surgical procedure used is oversewing the perforation and covering it with omentum, and there are no case reports of neonatal duodenal perforation treated by omentum plugging. In adult cases, omentum plugging is often preferred because it is safe and requires a small number of sutures. Moreover, wound healing promotion by omentum plugging is expected. Omentum plugging for duodenal perforation appears to be suitable for neonates.

Surgery for rectovestibular fistula with a normal anus is problematic because of the high incidence of recurrence. We performed perineal body repair for rectovestibular fistula in three children. During the surgery, a transverse incision was made in the perineal skin at the lithotomy position, and the perineum was dissected deeply to reach the perineal body, and a fistula was removed. The external extension of the perineal body, a connective tissue mass extending laterally from the perineal body to the left and right sides, was identified; this was tractioned bilaterally to the median and then closed by suture in layers from the depths to reshape the perineal body. Two of the three patients had a history of labial swelling at one month of age, and fistulas were found in the vestibular region. One patient became aware of vaginal gas at around 10 years of age, and at 12 years of age, stool began to leak from the vagina, and an intraoperative fistula running from the left side of the vestibule to the rectum on the oral side of the dentate line was observed. All patients had a good postoperative course without recurrence, infection or defecation problems. This technique can be used in patients with fistulas that do not have a clear site or after a recurrence.