Ryuta Saka

A case of tracheal agenesis surviving without mechanical ventilation after external esophageal stenting.

Tracheal agenesis is a rare and usually lethal congenital malformation of the forgut. Although some infants can be resuscitated with an intra-esophageal intubation temporarily, long-term airway management is difficult because of the collapsing airway. We report a long-term survivor with tracheal agenesis in whom a Gortex external esophageal stent using radial traction sutures was applied to prevent the esophagus from collapsing. The patient was discharged from our hospital without mechanical ventilation or oxygen inhalation at 10 months of age. Our procedure has a potential to establish a long-term steady airway in patients with tracheal agenesis. The detail of the procedure is presented and the related literature is reviewed.

Safety and Efficacy of Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernias and Hydroceles in Children: A Comparison with Traditional Open Repair

INTRODUCTIONnLaparoscopic procedures for inguinal hernias and hydroceles in children have become widespread in the past few decades. The purpose of this study was to perform a retrospective analysis of our experience in order to assess the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) and to compare the findings with those of conventional open repair (OR).nnnSUBJECTS AND METHODSnWe analyzed the medical records of 488 patients who underwent LPEC or OR for inguinal hernia or hydrocele at our institute between April 2008 and December 2012. The indications for the operation, length of the operation, complications, day surgery, contralateral patent processus vaginalis, and incidence of metachronous contralateral hernia were investigated. The chi-squared test, unpaired t test, and Steel-Dwass test were used to analyze the significance of the data.nnnRESULTSnAmong a total of 488 patients, 326 patients underwent LPEC (125 males and 201 females), and 162 underwent OR (140 males and 22 females). There was no significant difference in the incidence of recurrence (three in the LPEC and none in the OR group, P=.55) or in the success rates of day surgery (97.8% in LPEC versus 97.6% in OR). The incidence of metachronous contralateral hernias in the LPEC group was lower than that in the OR group (LPEC 0%; OR 2.2%, P=.03). Seventeen subjects with hydroceles were treated by LPEC without any complications.nnnCONCLUSIONSnLPEC is safe and effective for inguinal hernias and hydroceles in children, regardless of age, sex, and incarceration and could reduce the incidence of metachronous contralateral hernias.

Successful treatment of a 14-year-old patient with intestinal malrotation with laparoscopic Ladd procedure: case report and literature review

Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

A sutureless technique using cyanoacrylate adhesives when creating a stoma for extremely low birth weight infants

PurposeIntestinal perforation and necrotizing enterocolitis (NEC) are neonatal intestinal emergencies that are especially common in premature infants. While prompt surgical intervention, including stoma creation, is often required, the optimal surgical treatment has been controversial because of the substantial risks related to the stoma creation and management. The use of a tissue adhesive may have some advantages over the use of sutures when creating an intestinal stoma in extremely low birth weight (ELBW) infants. The purpose of this report was to present a novel approach for creating a stoma using a tissue adhesive in ELBW infants.MethodsA total of eight ELBW infants that underwent laparotomy with the creation of intestinal stomas using cyanoacrylate adhesive at our institution between 2009 and 2014 were enrolled. The clinical parameters, including the length of the operation, intra- and postoperative complications and the outcomes were evaluated.ResultsThe median body weight and gestational age at birth were 630xa0g and 24.3xa0weeks, respectively. The median age at referral was 11.5xa0days. The median length of the procedure was 58.5xa0min, including the inspection and resection of the intestine. All procedures were completed without any intraoperative complications. There were no postoperative complications associated with the stoma. Two patients died of the associated septic status.ConclusionsSutureless enterostomy using cyanoacrylate adhesive is a simple technique which has the potential to reduce the incidence of complications related to the intestinal stoma in ELBW infants.

Long-term outcomes of four patients with tracheal agenesis who underwent airway and esophageal reconstruction

PURPOSEnThe aim of this study was to evaluate the long-term outcomes of four patients with tracheal agenesis who underwent airway and esophageal/alimentary reconstruction.nnnMATERIALS AND METHODSnWe reviewed the medical records of four long-term survivors of tracheal agenesis and collected the following data: age, sex, type of tracheal agenesis, method of reconstruction, nutritional management, and physical and neurological development.nnnRESULTSnThe patients consisted of three boys and one girl, who ranged in age from 77 to 109months. The severity of their condition was classified as Floyds type I (n=2), II (n=1), or III (n=1). Mechanical respiratory support was not necessary in any of the cases. Esophageal/alimentary reconstruction was performed using the small intestine (n=2), a gastric tube (n=1), and the esophagus (n=1). The age at esophageal reconstruction ranged from 41 to 55months. All of the cases required enteral nutrition via gastrostomy. Three of the patients were able to swallow a small amount of liquid and one was able to take pureed food orally. The physical development of the subjects was moderately delayed-borderline in childhood. Neurological development was normal in two cases and slightly delayed in two cases.nnnCONCLUSIONSnNone of the long-term survivors of tracheal agenesis required the use of an artificial respirator, and their development was close to normal. Future studies should aim to elucidate the optimal method for performing esophageal reconstruction to allow tracheal agenesis patients to achieve their full oral intake.

Treatment and ovarian preservation in children with ovarian tumors

BACKGROUND/PURPOSEnOvarian preservation is desirable in children with ovarian tumors. However, the diagnostic and treatment strategies are heterogeneous. The aim of this study was to investigate the management and preservation of ovarian tissue in order to identify the factors associated with ovarian preservation.nnnMETHODSnThirty-seven patients (41 ovaries) were surgically treated for ovarian tumors. Four cases were bilateral. The data on the patient symptoms at presentation, imaging, treatment, outcome, pathology, and status of ovarian preservation were retrospectively analyzed for each patient.nnnRESULTSnHistological examinations revealed 25 mature teratomas, 5 immature teratomas, 5 cystadenomas, 2 dysgerminomas, and other tumors. Ovarian torsion occurred in 16 ovaries (39%). Ovary-sparing surgery was performed in 22 ovaries (53.7%). Successful ovarian preservation was significantly associated with a smaller tumor size, benign pathology, and a lower degree of torsion (P<0.01).nnnCONCLUSIONSnBecause the prognosis was favorable in most cases, the preservation of fertility and gonadal function should be a goal in the surgical treatment of ovarian tumors. We recommend ovary-sparing surgery as the first-line treatment for all pediatric ovarian tumors other than those that are preoperatively diagnosed as being malignant and those in which emergent surgical intervention is indicated owing to the suspicion of ovarian torsion.

Laparoscopic-assisted percutaneous endoscopic gastrostomy: a simple and efficient technique for disabled elderly patients.

BACKGROUND/PURPOSEnPercutaneous endoscopic gastrostomy (PEG) is a simplified catheter placement procedure for alimentation. Although the endoscopic approach to gastrostomy tube placement is a safe and well-tolerated procedure in most patients, the PEG procedure is difficult in elderly patients disabled since childhood who have severe scoliosis and malpositioning of the stomach. We describe a simple and effective laparoscopic-assisted PEG (LAPEG) technique that can be used for catheter placement in severely disabled patients.nnnMETHODSnThirteen severely disabled patients aged 14-57 years underwent gastrostomy tube placement with the LAPEG technique. After general anesthesia was achieved, an endoscope was placed into the stomach. Then, a 5-mm camera port was inserted at the umbilicus, and a 3-mm working port was inserted to identify and lift the optimal site for gastrostomy tube placement. After the 4-point fixation of the stomach, the 20-Fr gastrostomy tube was placed under endoscopic and laparoscopic observation.nnnRESULTSnAll patients tolerated the procedure well, and there were no major complications. The procedure was successful, and all patients could feed via the tube.nnnCONCLUSIONSnElderly disabled patients who have been bedridden since childhood often have severe scoliosis and malpositioning of the stomach. Our LAPEG procedure is effective, well tolerated, and safe for gastrostomy tube placement in such elderly patients.

Chronic ileocolic intussusception due to transmural infiltration of diffuse large B cell lymphoma in a 14-year-old boy: a case report.

Chronic intussusception, defined as intussusception continuing over 14xa0days, is rare in children. We herein report a case of chronic ileocolic intussusception caused by the transmural infiltration of diffuse large B cell lymphoma in a 14-year-old boy. The patient had been suffering from anorexia and intermittent abdominal pain for 5xa0weeks, during which his body weight decreased by around 7xa0kg. Upon admission to our hospital, ultrasonography and enhanced computed tomography (CT) of the abdomen showed ileocolic intussusception. A retrospective examination of abdominal CT led us to suspect that the intussusception had initially appeared 5xa0weeks before admission, presumably coinciding with the beginning of the patient’s abdominal symptoms. Since hydrostatic reduction was unsuccessful, laparotomy was performed, which showed unreducible ileocolic intussusception with a marked edematous ileum and mesentery. Ileocecal resection without lymph node dissection was carried out, and a histological examination of the resected specimen revealed the transmural infiltration of diffuse large B-cell lymphoma of the terminal ileum. The patient’s postoperative course was uneventful, and adjuvant chemotherapy was administered. This case illustrates the diagnostic challenges of confirming ‘chronic’ intussusception in older children.

Aggressive Graft Volume Reduction in Pediatric Living Donor Liver Transplantation under One Year Old Patients

Introduction Left lateral segment grafts are generally used for very young pediatric living donor liver transplantation (LDLT), however large-for-size grafts were sometimes seen then resulted in graft loss. The ideal graft volume (GV) is unknown in pre transplant assessment. Recently graft reduction techniques were developed. For example mono segment graft is applied to new born LDLT. We studied relations between estimated GV and actual GV, then assessed reduction techniques under 1-year old patients. Method The recipients under 1-year old who received LDLT between January 2006 and October 2017 were gathered. All donors of LDLT were their parents. Left lateral lobe or left lobe was resected as a graft from the donor. Graft reduction was performed with hemostat crushing technique on back table. Otherwise it was performed after reperfusion with Cavitron Ultrasonic Surgical Aspirator (CUSA) or linier stapler. Pre transplant standard liver volume (SLV) was estimated with Urata’s equation from patients height and body weight (BW). Graft type, graft weight (GW) and native liver weight were assessed. Liver specific gravity was approximated to 1.0 g/ml. Results Twenty-three patients were gathered. Original diseases were biliary atresia (n=17), fulminant hepatitis (n=5) and progressive familial intrahepatic cholestasis type 2 (n=1). Final graft types were left lobe (n=1), left lateral lobe (n=13), reduced left lateral lobe (n=6), segment 2 mono segment (n=1) and reduced segment 2 mono segment (n=2). Final GW/BW after reduction was median 3.2% (ranged 1.7% to 4.5%). Native liver weight/SLV was median 164% except for fulminant hepatitis. GW/native liver weight was median 53%. Pre reduction GV/estimated GV was median 102% but it was fluctuated between 77% and 186%. Estimated GV/SLV of lateral segment graft that required reduction (n=9) was median 112% (ranged 86% to 154%), final reduced graft GV/SLV was median 86% (ranged 74% to 122%). Complications due to large for size graft was unable closure of abdomen and portal vein thrombosis in one case with GV/SLV 122%. No complication was seen based on graft reduction like bleeding or bile leakage. All reduced grafts worked well. Discussions Estimated GV in very young patients under 1-year old varied widely, therefore unexpected large for size graft after donor liver resection was sometimes seen. There were room for implant in the cases except for fulminant hepatitis because native livers were enlarged, however smaller graft is better in terms of portal blood supply. Aggressive volume reduction of graft is recommended to avoid complications based on large for size graft. Mono-segment graft can be useful not in over newborn patients. Conclusion Estimated GV in very young patients under 1-year old varied widely, Aggressive volume reduction of graft including mono segment is recommended.

Postoperative Platelet Count can Predict Splenic Volume Expansion after Living Donor Liver Transplantation in Pediatric Patients with Biliary Atresia

Introduction Although spleen volume (SV) has been thought to decrease after living donor liver transplantation (LDLT), there are a few cases in which SV gradually increases and the expansion can lead to life-threatening complications. However, it is unclear which patients have such a risk. This study was conducted to investigate factors associated with SV expansion after LDLT. Materials Patients with liver cirrhosis due to biliary atresia (BA), who had LDLT between March 2008 and July 2017 in our institute, were included in this study. CT scan was performed approximately 3 months (3±1 months) after LDLT. Those patients, who had splenectomy with LDLT simultaneously and who died within 3 months after LDLT, were excluded. Methods Age, sex, standard liver volume (SLV) for each patient, transplanted graft volume (GV), SV before and approximately 3 months after LDLT were evaluated. The major, minor and longitudinal diameter of spleen were measured on the cross-sectional surface with splenic hilar. SV was calculated by multiplying these values and evaluated as SV/body surface area (BSA) to compare patients with variable ages. Patients were divided into SV/BSA ≥1,000ml and <1,000ml. The volume reduction rate was calculated using the formula of [((Preoperative SV) – (Postoperative SV))/Preoperative SV]×100. Using this rate, patients were divided into two groups; SV reduction and SV expansion. Factors which could affect postoperative SV were evaluated using the univariable regression analysis. The impact of postoperative Plt on SV expansion was measured with the logistic regression analysis. Results 33 patients (11 males and 22 females) were enrolled.The mean age of these patients was 3.7±5.4 years old. The mean GV/SLV and GV/body weight were 76.8±22.1% and 2.47±0.94%, respectively. The mean SV/BSA before and after LDLT, and SV reduction rate were 780.8±287.0ml/m2, 569.2±254.7ml/m2 and 23.4±31.0%, respectively. There were five patients whose SV increased postoperatively. The mean age and postoperative Plt of patients with preoperative SV/BSA ≥1,000ml was significantly older and lower than those with <1,000ml (p=0.0016 and 0.039, respectively). All laboratory values except Plt were significantly improved after LDLT, and there was a significant difference in postoperative Plt between SV reduction and SV expansion groups (19.0±7.8 and 10.7±5.6 (×104/&mgr;l), respectively (p=0.031)). In the univariable regression analysis, postoperative Plt had a significant effect on SV reduction rate (regression coefficient, 1.52 (CI 0.23-2.82; p=0.022)). In the logistic regression analysis, there was a significant impact of postoperative Plt on SV expansion after LDLT (OR 0.808 (CI 0.661-0.988; p=0.038)). Figure. No caption available. Figure. No caption available. Figure. No caption available. Discussion/Conclusion Remaining low Plt after LDLT could indicate the poor SV reduction and may predict SV expansion. Adolescent patients with preoperative SV/BSA ≥1,000ml should undergo splenectomy with LDLT.