Masashi Nakahira

Indications for surgical treatment of funnel chest by chest radiograph

Abstract. Forty-seven children with funnel chest (FC) who underwent sternal elevation and 210 normal children were examined to determine the indications for surgical treatment using the vertebral index (VI) and frontosagittal index (FSI). In normal children VI gradually increased and FSI gradually decreased with age. Both indices changed significantly at 3 years of age. Although the VI of FC patients decreased significantly from 33.8 ± 7.6 (n=40) to 24.4 ± 3.9 (n=38) postoperatively (P < 0.0001), it was significantly larger than that of normal children over 3 years of age (20.2 ± 2.2, n=150) (P < 0.0001), and although the FSI of FC patients increased significantly from 22.0 ± 7.0 (n=40) to 34.5 ± 6.5 (n=38) postoperatively (P < 0.0001), it was significantly smaller than that of normal children over 3 years of age (41.1 ± 4.0, n=150) (P < 0.0001). Since many patients had a thin and flat chest despite excellent correction, their postoperative indices were not normal. There was a correlation between VI and FSI in normal children and a high degree of correlation between VI and FSI both before and after operation in FC patients. We conclude that a VI of more than 27 and/or a FSI of less than 29 are indications for surgical treatment based on the mean VI + 3SD and FSI − 3SD of normal children over 3 years of age. These values are almost equal to the mean VI − SD and FSI + SD of patients with physical, cosmetic, and/or psychological disturbances. However, it is not necessary to measure both indices simultaneously. Postoperative VI and FSI did not always reflect the degree of chest-wall depression in FC patients because of their flat chests.

Manometric diagnosis of Hirschsprung's disease in the neonatal period

A newly designed semiconductor manometer was assembled for anorectal manometry in the neonatal period. Sixty apparently healthy neonates and 17 patients who presented gastrointestinal obstructive symptoms were examined by the eighth day of life. All 60 apparently healthy neonates showed a normal fluctuating wave and rectoanal reflex. Prematurity and postnatal age do not influence the normal rectoanal reflex. Among 17 patients, 5 were diagnosed as having Hirschsprungs disease based on absence of the reflex. There were no false negative or false positive results among these cases. It appears that anorectal manometry could be a reliable diagnostic test of Hirschsprungs disease even in the neonatal period.

Indications for surgical repair of funnel chest based on indices of chest wall deformity and psychological state.

AbstractPurpose. We examined the surgical indications for funnel chest, taking psychological factors into consideration. Methods. We assessed 36 young people with funnel chest who were seen as outpatients, including 31 boys and 5 girls aged from 1 to 22 years old. Respondents were asked whether they suffered psychological distress, and if they wanted surgery. The severity of the deformity was evaluated using the Vertebral Index (VI) and the Frontosagittal Index (FSI) calculated from chest roentgenograms. Results. The VI in 11 patients without distress (23.7 ± 4.1) was lower than that in 25 patients with distress (32.8 ± 8.2), and the FSI in the patients without distress (33.5 ± 5.3) was higher than that in the patients with distress (23.6 ± 8.6). The VI in 19 patients who did not want surgery (26.9 ± 7.9) was lower than that in 17 patients who did (33.5 ± 7.5), and the FSI in the patients who did not want surgery (30.4 ± 8.1) was higher than that in the patients who did (22.4 ± 8.1). The distressed patients suffered many psychological problems, such as being the object of bullying. Conclusion. The severity of the deformity affected the patients psychological state. We consider that a VI ≫28 or an FSI ≪28 are indications for surgery, based on the mean VI + SD and the mean FSI-SD of patients not suffering distress.

Perineal groove and perineal canal.

Perineal groove is a rare congenital wet sulcus extending from the fourchette to the anus. With awareness of the lesion, surgery can be avoided. Perineal canal is a congenital anorectovestibular fistula coexistent with normal anus. Recently, it has become evident that these lesions are relatively common and clinically important variants of anorectal anomalies. We now report one patient each with these anomalies and briefly review the surgical problems.

A method of delayed esophageal anastomosis for high-risk congenital esophageal atreasia with additional intraabdominal anomalies; Transgastric balloon “fistulectomy”

Congenital esophageal atresia with associatedabdominal anomalies such as duodenal atresia or high anorectal malformations may be treated safely by delayed esophageal anastomosis after operative correction of abdominal anomalies. Transgastric balloon “fistulectomy” (TBF) has been devised to make possible a prolonged delay of the esophageal anastomosis.

Esophagitis in infants with hypertrophic pyloric stenosis: A source of hematemesis

This study was undertaken to clarify the source of blood in the vomitus of patients with hypertrophic pyloric stenosis (HPS). Twenty-one infants with HPS were examined. Hematemesis was noted in 14 infants. Esophagogastric endoscopy showed a 100% incidence of esophagitis and in one patient gastric erosion was also observed. Histological study of the esophageal mucosa showed evidence of esophagitis in 18 patients (85.7%). Preoperative pH monitoring showed gastroesophageal reflux (GER) in all infants. Excessive acid exposure (> or = 7%) was significantly correlated with the grade of esophagitis and the incidence of hematemesis, whereas acid exposure time was shorter in the cases without histological esophagitis. These results suggested that the source of bleeding in HPS is the esophageal mucosa affected by esophagitis secondary to excessive acid reflux. Although there is obvious massive gastroesophageal reflux in HPS, it is too difficult to evaluate the lower esophageal sphincter function in HPS.

Neonatal gastric perforations; A diagnostic clue in pre-perforative phase

This paper is a retrospective analysis of the pre-perforative clinical picture in twenty-seven neonates with gastric perforations. In fifteen there was a remarkably consistent progressive pattern in the preperforative clinical course. We separated the clinical course of the disease into three distinct stages in relation to pathological changes in the gastric wall i.e. gastric ischemia and dysfunction, transmural peritonitis and paralytic ileus, and actual perforation. Emphasis was placed on the existance of a clinically detectable pre-perforative phase which, if interpreted correctly, should lead to earlier diagnosis and consequently more satisfactory therapeutic results.