Jun Iwai

Nonoperative management of blunt pancreatic injury in childhood

PURPOSE Nonoperative management for blunt pancreatic injury in children was performed between 1977 and 1998. The efficiency and safety of nonoperative management was examined. METHODS Pancreatic injury was diagnosed in 20 children. The surgical indication was determined by hemodynamic instability and the management of associated injuries. Children without surgical indications were treated initially by nonoperative management. RESULTS Nineteen of 20 children were treated initially nonoperatively, and 18 of the 19 survived. Surgical exploration was performed in only 1 child with perforation of the duodenum and bile duct. One child died of complications of total parenteral nutrition. Ultrasound scan and computed tomography scan showed pancreatic contusion in 9, laceration in 6, and injury of the main pancreatic duct (MPD) in 5. Pseudocysts were detected in 10 (5 laceration and 5 MPD injury). Pseudocysts smaller than 10 cm disappeared after nonoperative management, and those larger than 10 cm required operative management. Rupture of pseudocysts occurred in 2 children by rotating the upper torso. CONCLUSIONS Nonoperative management of pancreatic injuries is effective in children, although careful management is required to avoid complications. Pseudocysts smaller than 10 cm were treated successfully by nonoperative management, and those larger than 10 cm required surgical management.

Neuronal src and trk A protooncogene expression in neuroblastomas and patient prognosis

Neuroblastomas present a wide variety of clinical and biological behaviors, which are reflected by the heterogeneous expressions of protooncogenes related to the neuronal differentiation and amplification of the N‐myc gene. High expression of trk A and Ha‐ras in neuroblastomas has been shown to be associated with an excellent patient outcome. We have previously reported that neuron‐specific src mRNA was increased in chemically differentiated neuroblastoma cell lines and in clinically observed neuroblastomas without N‐myc amplification. In the present study, to clarify both the value of neuronal c‐srcN2 expression as a prognostic indicator and the significance of the coexpression of these protooncogenes, we examined the expression of 3 alternatively spliced src, trk A and Ha‐ras in neuroblastoma tissues from 60 patients by competitive RNA‐polymerase chain reaction (PCR). The results indicate that protooncogene expression in neuroblastomas correlated with a favorable outcome for c‐srcN2 and trk A. N‐myc gene was amplified exclusively in tumors with low levels of trk A. Low expression of c‐srcN2 and trk A might thus characterize different aggressive phenotypes due to different signal transduction pathways of neural differentiation in neuroblastoma. The combined analyses for c‐srcN2 and trk A expression by RNA‐PCR should provide information about the biological phenotype of a neuroblastoma within a short period of time after obtaining tumor material. Int. J. Cancer (Pred. Oncol.) 79:226–231, 1998.© 1998 Wiley‐Liss, Inc.

Strangulated umbilical hernia in a child: report of a case.

Abstract Most umbilical hernias in children close spontaneously. Complications associated with umbilical hernias are rarely observed during follow-up. We report herein a 5-month-old girl with a strangulated umbilical hernia. Her umbilicus was hard, reddish, and irreducible. Plain radiography of the abdomen showed signs of mechanical ileus. The patient was thus diagnosed to have a strangulated umbilical hernia. A 5-cm section of the ascending colon and a 5-cm section of the terminal ileum, as well as the cecum and appendix, were congested, edematous, and erythematous, and together were enclosed by a firm hernial ring. A closure of the fascial defect and umbilicoplasty were performed. The postoperative course was uneventful. In patients with infantile umbilical hernias, strangulation may occur as the fascial defect decreases in size.

Effective endless-loop bougienage through the oral cavity and esophagus to the gastrostomy in corrosive esophageal strictures in children

The authors present a safe, conservative method of endless-loop bougienage (ELB) through the oral cavity and esophagus to a gastrostomy without general anesthesia in three children with corrosive esophageal burns treated since 1966. Esophagogastroscopy was performed to evaluate for esophagitis at an early phase after ingestion of the caustic substance. When esophageal stricture formation was recognized after subsequent conservative treatment, a feeding gastrostomy was made. A continuous string loop with plummets of progressively larger size was positioned to pass through the patients oral cavity and esophagus to the gastrostomy. Strictures were found in the upper esophagus in two patients and in the middle and lower esophagus in one. The gastrostomy was performed 15␣months, 20 days, and 2 months after the injury, respectively, and the periods of ELB were 3, 5, and 2½␣years, respectively. The patients were able to start eating at 26, 42, and 29 months after injury, respectively. They are now 30, 18, and 17 years old, and slight dysphagia remains in patients 1 and 2. No patient developed esophageal carcinoma at the site of the corrosive stricture. Our method of ELB through the patients oral cavity and esophagus to the gastrostomy appears to be safe, reliable, and useful. We believe that most caustic esophageal strictures in children can be treated by this conservative measure.

Imaging of neuroblastoma in patients identified by mass screening using urinary catecholamine metabolites

Between April 1983 and August 1991, mass screening in Chiba Prefecture found 25 infants to be positive for neuroblastoma based on elevated urinary levels of catecholamine metabolites. Ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy (BS), and 67Ga scintigraphy (GS) detected neuroblastomas in 12 of the 25 infants. The primary site of tumor was the mediastinum in 1 patient, the adrenal gland in 7, retroperitoneum in 3, and pelvis in 1. To determine the accuracy of each imaging technique, the percent sensitivity (SE), percent specificity (SP), and percent accuracy (AC) were determined for each technique from surgical findings and a follow-up study. MRI showed the highest diagnostic accuracy (100% for SE, SP, and AC), followed by CT (100%, 92%, 96%), US (82%, 92%, 88%), BS (58%, 100%, 80%), and GS (42%, 85%, 64%) in that order. MRI is most suitable for the imaging of individuals judged to be positive in the mass screening for neuroblastoma because of the advantages of visualization of the spread of tumor and the relationship of tumor to the great blood vessels, important determinants of resectability and therapy.

Renal impairment after surgical resection of neuroblastoma

Postoperative renal impairment was observed in 6 of 58 patients with neuroblastoma treated between November 1982 and March 1994. To clarify the clinical characteristics of these patients (renal-impairment group), they were compared with 26 patients treated during the same period who did not have renal impairment (no-impairment group). The incidence of primary retroperitoneal tumor and invasion of the hilum renalis was clearly higher in the renal-impairment group than in the group with no impairment. However, no significant difference was observed with respect to age, tumor laterality, or stage of disease. The results of postoperative biochemical examinations showed that the serum concentrations of lactic dehydrogenase were significantly higher in the renal-impairment group. In the group with renal impairment, the mean maximal body temperatures on the first, second, and third postoperative days were 38.7 degrees C, 38.6 degrees C, and 38.1 degrees C, respectively. These were higher than those of the no-impairment group. For patients with these risk factors, intraoperative prophylactic measures and early postoperative renal blood flow evaluation (in anticipation of postoperative renal impairment) are considered necessary.

Long-term survival in a patient with congenital laryngeal atresia and multiple malformations.

Abstract Laryngeal atresia (LA) is an uncommon congenital anomaly, and only a few cases with long-term survival are reported in the literature. The authors describe a 2-year-old boy with LA and esophageal (EA), intestinal, and urethral atresia (UA). Immediately after birth, severe respiratory distress and mild abdominal distension became evident. Endotracheal intubation was unsuccessful and emergency tracheal puncture was performed, after which a tracheostomy was constructed. Direct laryngoscopy revealed LA at the vocal cord level. A cystostomy and gastrostomy were constructed immediately because of UA and EA. A cystocutaneostomy, ileocolic anastomosis, and resection of a tracheoesophageal fistula (TEF) were simultaneously performed 1 day after birth. The EA was proximal with a distal TEF. The gap between the ends of the upper and lower esophagus was 4 cm in length. It was thought impossible to perform a primary anastomosis, and therefore, a gastrostomy and resection of the TEF using multiple-stage surgery was undertaken. Intestinal resection and anastomosis were performed due to intestinal stenosis from necrotizing enterocolitis at the age of 3 months. Hypoxic encephalopathy developed due to accidental obstruction of the tracheostomy tube at the age of 10 months, and physical therapy was begun. He required a cutaneous nephrostomy due to a right hydromegaureter with vesicoureteric reflux and a left non-functioning kidney at the age of 23 months. He has been hospitalized for partial ventilatory assistance for 2 years at our institution. The course of this patient seems noteworthy in relation to the genesis of the multiple malformations.

Management of Defecation in Spina Bifida

The main presenting complaint in defecational disorders in spina bifida is constipation. The principal cause of this complaint is hypofunction or paralysis of muscles in the pelvic floor as a result of the spinal cord injuries. To evaluate the present status of defecation, anorectal manometry with special reference to the anorectal pressure profile has been useful. The possibility of using anorectal manometry for the research of anorectal movement and participation of spinal cord was discussed.