Michimasa Fujiogi

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.

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.

Five neonatal cases of pyriform sinus fistula with cervical cystic lesion: a comparison between sonography and other modalities

Pyriform sinus fistulas are an unusual cause of neck cystic lesions in neonates. A definitive diagnosis requires detection of the fistula, which originates from the pyriform sinus and extends to the cystic lesion. Sonography has been reported to be useful for detecting fistulas. However, there have been no reports of neonatal cases in which sonography could detect fistulas not detected by other modalities, such as barium esophagography, computed tomography (CT), or magnetic resonance imaging (MRI). We describe five neonatal patients with pyriform sinus fistula-appearing cervical cystic lesions. All patients were examined by sonography; of these, three patients were also examined by barium esophagography, two by CT, and one by MRI. The fistula was detected by sonography but not CT in one patient and by barium esophagography but not MRI in one. Two patients whose fistulas were detected by sonography had an oval-shaped and relatively small cystic lesion. One patient whose fistula could be detected only by barium esophagography had a relatively large cystic lesion. In two patients, whose fistulas were not detected by sonography or barium esophagography, sonography revealed air bubbles within the cystic lesions, and a pyriform sinus fistula was suspected. Without requiring ionizing radiation, sonography was thus useful in diagnosing pyriform sinus fistula-appearing cervical cystic lesions in neonatal cases. On the other hand, in two patients whose fistulas were not detected by sonography, the shape of the cystic lesion was polygonal or multicystic. In two of three patients with infectious signs, a fistula could not be detected. The shape and size of the cystic lesion and the presence of infectious signs may be important factors for detecting fistulas.

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.

Lateral cervical sinus: specific sonographic findings in two pediatric cases.

A lateral cervical sinus, also known as a second pharyngeal or branchial cleft fistula/sinus, occurs when the second pharyngeal arch fails to grow caudally over the third and fourth arches, leaving remnants of the second branchial clefts in contact with the surface of the neck via a narrow canal. This type of sinus is detected on the lateral aspect of the neck directly anterior to the sternocleidomastoid muscle. We report two pediatric cases with lateral cervical sinus, and pathognomonic sonographic findings to confirm the diagnosis. The first case involved a 3-month-old boy with a sinus on the lateral neck and occasional drainage from a cervical sinus opening. Sonography revealed that the sinus tract extended between the external and internal carotid arteries. In case two, a 1-month-old girl presented with a sinus on the lateral neck and signs of acute infection at the site of a pinpoint opening. Sonography revealed an oval-shaped cystic lesion and sinus tract extending between the external and internal carotid arteries. Sonography does not require radiation or sedation for children. The best choice for the first examination for lateral cervical sinus is sonography, rather than CT, MRI, or contrast fistulograms.

Outcomes following laparoscopic versus open surgery for pediatric inguinal hernia repair: Analysis using a national inpatient database in Japan

BACKGROUND This study compared perioperative outcomes between laparoscopic surgery (LS) and open surgery (OS) for pediatric inguinal hernia repair, using a national inpatient database. METHODS Using the Diagnosis Procedure Combination database in Japan, we compared duration of anesthesia, postoperative complications, recurrence, and metachronous hernia (MH) between LS and OS for children undergoing inguinal hernia repair from July 2010 to March 2016. We used multivariable logistic regression analysis for postoperative complications and Cox regression analysis for recurrence. RESULTS For 75,486 eligible patients (LS 20,186 vs. OS 55,300), the median follow-up was 815 (381-1350) days in LS and 1106 (576-1603) days in OS. The duration of anesthesia was significantly longer in LS than in OS for unilateral surgery (80 vs. 70min, p<0.001) but shorter for bilateral surgery (86 vs. 96min, p<0.001). LS had a lower proportion of MH than OS (0.3% vs. 3.4%, p<0.001). There was no significant difference between LS and OS in complications (odds ratio: 0.55; 95% confidence interval: 0.22-1.38; p=0.20) or recurrence (hazard ratio: 1.24; 95% confidence interval: 0.86-1.79; p=0.89). CONCLUSIONS LS patients had lower proportions of MH than OS patients. Complications and recurrence did not differ significantly between LS and OS. TYPE OF STUDY Retrospective study. LEVELS OF EVIDENCE Level III.

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.

Contraindications and image-defined risk factors in laparoscopic resection of abdominal neuroblastoma

PurposeMinimally invasive surgery (MIS) has become widely accepted as a technique for abdominal neuroblastoma resection. However, the indications for MIS are still controversial. The aim of this study was to evaluate image-defined risk factors (IDRFs), complications, and oncologic outcomes in patients with abdominal neuroblastomas treated with MIS.MethodsBetween August 1998 and February 2016, MIS was planned for 20 children with abdominal neuroblastomas. Clinical data were retrospectively reviewed and compared between the IDRF-negative and IDRF-positive patients.ResultsOn the basis of the latest IDRF guidelines, five patients were classified as IDRF-positive and four of them had operative complications; namely, partial infarction of the ipsilateral kidney or open conversion. Concerning the two patients who needed open conversion, the primary reason for open conversion was difficulty in dissection of the tumor from the vena cava. Preoperative images of these cases showed either deformation or subtotal encasement of the vena cava. Relapse occurred in three high-risk patients and in none of the low/intermediate-risk patients. No complication occurred in the IDRF-negative cases.ConclusionsIDRF-negative might be a good indication for MIS for abdominal neuroblastoma. However, deformation or subtotal encasement of the vena cava should be considered as IDRF-positive for MIS.

Laparoscopic side-to-side pancreaticojejunostomy for chronic pancreatitis in children.

Surgical pancreatic duct (PD) drainage for chronic pancreatitis in children is relatively rare. It is indicated in cases of recurrent pancreatitis and PD dilatation that have not responded to medical therapy and therapeutic endoscopy. We performed laparoscopic side-to-side pancreaticojejunostomy for two paediatric patients with chronic pancreatitis. The main PD was opened easily by electrocautery after locating the dilated PD by intraoperative ultrasonography. The dilated PD was split longitudinally from the pancreatic tail to the pancreatic head by laparoscopic coagulation shears or electrocautery after pancreatography. A laparoscopic side-to-side pancreaticojejunostomy was performed by a one-layered technique using continuous 4-0 polydioxanone (PDS) sutures from the pancreatic tail to the pancreatic head. There were no intraoperative or postoperative complications or recurrences. This procedure has cosmetic advantages compared with open surgery for chronic pancreatitis. Laparoscopic side-to-side pancreaticojejunostomy in children is feasible and effective for the treatment of chronic pancreatitis.