Kyoichi Deie

Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis

PURPOSE Although nonoperative treatment for uncomplicated appendicitis is now an accepted approach, there are few reports in children. The aim of this study was to compare long-term outcomes between operative and nonoperative treatment in children. METHODS Between April 2007 and December 2013, all uncomplicated appendicitis patients were asked to select either operative (laparoscopic surgery) or nonoperative treatment on admission. For nonoperative treatment, intravenous injection of antibiotics was continued until serum C-reactive protein concentration decreased to below 0.5mg/dL. A questionnaire survey on satisfaction with treatment was added afterwards and performed more than 1year after treatment. RESULTS Eighty-six patients chose operative treatment, and 78 chose nonoperative treatment. The success rate of nonoperative treatment was 98.7%. There was no difference in the length of hospital stay between the two groups. Ileus occurred in two operatively-treated patients, while recurrence of appendicitis occurred in 22 nonoperatively-treated patients (28.6 %) after an average of 4.3years of follow-up. The overall nonoperative treatment failure including both early failure and recurrence occurred more frequently among those with appendicoliths than without appendicoliths. Satisfaction levels were higher for operative treatment. CONCLUSIONS Although the success rate of nonoperative treatment was very high, a considerable number of patients experienced recurrence.

Single-incision laparoscopic-assisted appendectomy in children: exteriorization of the appendix is a key component of a simple and cost-effective surgical technique

PurposeSingle-incision laparoscopic appendectomy was recently introduced as a less-invasive surgical technique than existing methods, and is increasingly being performed worldwide. We have started to perform transumbilical laparoscopic-assisted appendectomy (TULAA) in children. In this study, we assessed its feasibility, efficacy, and cost-effectiveness compared with conventional multiport laparoscopic appendectomy (MLA).MethodsWe retrospectively reviewed all of the patients who underwent MLA or TULAA between August 2009 and December 2012. Patient characteristics, operative time, length of hospital stay, postoperative complications, cost-effectiveness, and cosmetic results were analyzed.ResultsA total of 88 patients underwent laparoscopic appendectomy, with MLA in 48 patients and TULAA in 40 patients. TULAA was successful in 36/40 patients. There were no significant differences in mean operative time or mean length of stay between the two groups of patients. There were no postoperative complications in the TULAA group. The cost of TULAA was much lower than that of MLA. TULAA also provided nearly scarless surgery.ConclusionTULAA, in which the appendix is exteriorized via a combination of open and laparoscopic techniques, is a safe and effective procedure for treating appendicitis in children. TULAA is a cost-effective treatment that provides excellent cosmetic results.

Complete Thoracoscopic Versus Video-Assisted Thoracoscopic Resection of Congenital Lung Lesions

BACKGROUND Minimally invasive surgery is recognized as a safe and feasible technique for resecting congenital lung lesions. In our hospital, video-assisted thoracoscopic surgery (VATS) was initially performed through a 5-6-cm incision with several trocars under differential lung ventilation (assisted-VATS). Complete thoracoscopic surgery (complete-VATS) with artificial pneumothorax was introduced in 2009 and allowed surgery in smaller infants. The aim of this study was to compare the outcomes of complete-VATS and assisted-VATS for congenital lung lesions. PATIENTS AND METHODS Between January 2004 and October 2012, 22 children underwent pulmonary lobectomy by complete-VATS or assisted-VATS at our hospital. We retrospectively reviewed the intraoperative and early postoperative results of these patients. RESULTS Of the 22 children, 10 underwent assisted-VATS, and 12 underwent complete-VATS to treat various diseases, including congenital cystic adenomatous malformation, sequestration, and bronchial atresia. The age, body weight, and mean operative time were not significantly different between the two groups. Four patients in the complete-VATS group, but none in the assisted-VATS group, weighed <10 kg. Intraoperative bleeding was significantly less, and hospital stay was significantly shorter, in the complete-VATS group. One patient in the assisted-VATS group had intraoperative bleeding and required conversion to open surgery. Postoperative complications included transient paralysis of the affected arm and transient atelectasis in 1 patient each in the complete-VATS group. CONCLUSIONS Complete-VATS can be safely performed with less bleeding and shorter hospital stay than assisted-VATS. As differential lung ventilation is not essential during complete-VATS, complete-VATS can be performed in small infants.

More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary?

BACKGROUND Although nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated. METHODS Between April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses. RESULTS Thirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group. CONCLUSION Although many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT. LEVEL OF EVIDENCE Prospective comparative study, level II.

The umbilical Benz incision for reduced port surgery in pediatric patients.

Background and Objectives: For reduced port surgery in pediatric patients, the initial umbilical incision plays an important role in both functional ability and cosmetic impact. Larger umbilical incisions enable better manipulation of forceps, extraction of larger surgical specimens, and easier exteriorization of the intestine for anastomosis. We have pursued an incision of the small pediatric umbilicus that allows for enlargement of the orifice of the abdominal opening with preservation of the natural umbilical profile. This article aims to present a new umbilical incision technique and describe the outcomes. Methods: We devised a new umbilical incision technique for reduced port surgery in pediatric patients. Our incision is made in an inverted Y shape (Benz incision), allowing for access port device insertion. The Benz incision technique was applied between November 2010 and May 2014 and was retrospectively studied. Results: Seventy-five patients underwent Benz incisions. The median age of all patients was 6 years 6 months (range, 26 days to 18 years), and the median body weight was 21.7 kg (range, 3.1–54.3 kg). Benz incisions were applied for various procedures, including reduced port surgery with hepaticojejunostomy for congenital biliary dilatation, portojejunostomy for biliary atresia, Meckel diverticulectomy, tumor resection, varicocelectomy, cholecystectomy, splenectomy, ileus surgery, ileocecal resection, and total colectomy. All patients were successfully treated, without a significant increase in operating time or severe complications. The cosmetic profile of the umbilicus was maintained after surgery. Conclusion: The Benz incision is a feasible, effective, and scarless approach for reduced port surgery in pediatric patients whose umbilical rings are too small for the conventional approach.

Urethroscopic holmium: YAG laser ablation for acquired posterior urethral diverticulum after repair of anorectal malformations

Two patients with acquired posterior urethral diverticulum that is a complication of laparoscopic assisted anorectoplasty underwent urethroscopic holmium: YAG laser ablation. After the ablation therapies, the size of the diverticulum markedly decreased in both patients. Holmium: YAG laser is safe and easy to handle in the small pediatric urethra.

Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: a single-center retrospective cohort study of 2028 cases

BackgroudRecently, laparoscopic percutaneous extraperitoneal closure (LPEC) has gained increased popularity for pediatric inguinal hernia repair. To improve cosmesis, we developed single incision LPEC (SILPEC). The aim of this study was to assess the safety and feasibility of SILPEC compared with traditional open repair (OR).MethodsThis was a single-center retrospective cohort study of 2028 children who underwent inguinal hernia repair between April 2005 and August 2014. Nine hundred and ninety-five patients underwent OR and 1033 patients underwent SILPEC. Medical records were reviewed with respect to operative time, recurrence, incidence of contralateral metachronous inguinal hernia (CMIH), and complications. Patient satisfaction with cosmetic result was also investigated using questionnaires sent by mail. ResultsAll SILPEC procedures were completed without conversion. Operative time was longer in the SILPEC group than in the OR group for both unilateral and bilateral surgery regardless of sex (unilateral male: p = 0.0006, unilateral female: p < 0.0001, bilateral male: p < 0.0001, bilateral female: p < 0.0001). There was no statistically significant difference in recurrence rate (p = 0.43). The incidence of CMIH was significantly higher in the OR than in the SILPEC group (p < 0.0001). No postoperative testicular atrophy was found in either group. There was no statistically significant difference in ascending testis (p = 0.09), but the frequency of surgical site infection was higher in the SILPEC than in the OR group (p = 0.0013). According to the questionnaire, operative scar was more invisible in the SILPEC than in the OR group (p < 0.0001), but both procedures had equally high levels of satisfaction for cosmetic results (p = 0.58). ConclusionSILPEC proved to be a safe and feasible procedure compared with OR with an equally low recurrence rate, more effectiveness for preventing CMIH, and more invisible scar.

Influence of surgical intervention on neurodevelopmental outcome in infants with focal intestinal perforation.

Intestinal perforation is known to correlate with neurodevelopmental outcome in very low‐birthweight (VLBW) infants, and its two major causes are necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP). Infants with FIP are reported to have better neurodevelopmental outcome than infants with NEC, but outcome has not been compared with that in infants without diseases that require surgery. The aim of this study was to compare neurodevelopmental outcomes between FIP survivors and infants without diseases that require surgery.

Towards robust needle segmentation and tracking in pediatric endoscopic surgery.

Neonatal tracheoesophageal fistula surgery poses technical challenges to surgeons, given the limited workspace and fragile tissues. In previous studies from our collaborators, a neonatal chest model was developed to allow surgeons to enhance their performance, such as suturing ability, before conducting actual surgery. Endoscopic images are recorded while the model is used, and surgeon skill can be manually assessed by using a 29-point checklist. However, that is a time-consuming process. In the checklist, there are 15 points that regard needle position and angle that could be automatized if the needle could be efficiently tracked. This paper is a first step towards the goal of tracking the needle. Pixel HSV color space channels, opponent color space channels, and pixel oriented gradient information are used as features to train a random forest model. Three methods are compared in the segmentation stage: single pixel features, pixel and its immediate 10-by-10 square window features, and the features of randomly offset pixels in a larger 169-by-169 window. Our analysis using 9-fold cross-validation shows that using randomly offset pixels increases needle segmentation f-measure by 385 times when comparing with single pixel color, and by 3 times when comparing with the immediate square window even though the same amount of memory is used. The output in the segmentation step is fed into a particle filter to track the full state of the needle.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible

ABSTRACT Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.