Shigeru Ono

Long-term outcomes of congenital tracheal stenosis treated by metallic airway stenting

AIM Congenital tracheal stenosis is an obstructive airway lesion that often presents as a life-threatening emergency. We had introduced the balloon dilatation and placement of the expandable metallic airway stent as a therapeutic option, and this study aimed to clarify the long-term outcomes in pediatric patients. METHODS A retrospective review of five infants in whom balloon expandable metallic airway stents (10-40 mm long and 6-8mm in diameter) were inserted in 1997 to 2000 was conducted. RESULTS There was an immediate improvement of respiratory obstruction in all five infants (aged 7 days to 12 months) with four weaned from ventilation. One child died after 9 months of palliative treatment. In all inflammation and granulation tissue developed over the stents, but this could be managed by scraping or balloon compression. Metallic stents have been in place a mean of 12 years (range 6 months to 13 years) after insertion without other complications. Four children are alive and well with their stents in place. Recently, an attempt to remove the stent was done in two patients who showed dyspnea on exertion. They underwent tracheoplasty following successful complete removal of metallic stent using cardiopulmonary bypass. CONCLUSION Use of expandable metallic airway stents following balloon dilatation can be left for long periods to relieve tracheal obstruction. Development of granulation tissue is a major treatable complication. Removal of the stent was safely completed by open surgical intervention using a cardiopulmonary bypass. The airway stent may provide an important therapeutic option in selected cases with congenital tracheal stenosis.

Double-balloon Enteroscopy for Pediatric Patients: Evaluation of Safety and Efficacy in 257 Cases.

Objectives: The safety and efficacy of double-balloon enteroscopy (DBE) in pediatric patients has not been well documented. We aimed to evaluate the clinical efficacy and safety of DBE in children, especially those under 10. Methods: We retrospectively analyzed our database of DBE procedures performed between September 2000 and September 2013. Procedures performed in pediatric patients (under 18) were selected from a total of 3980, including double-balloon endoscopic retrograde cholangioscopy (DBERC). Results: Two hundred fifty-seven DBE procedures were performed in 117 pediatric patients (median age 12.5 years). Antegrade (oral-route) DBE was performed in 166 procedures including 104 DBERC procedures (lowest body weight 13.5 kg, youngest age 3 years), and retrograde (anal-route) DBE in 91 (lowest body weight 12.0 kg, youngest age 2 years). The overall diagnostic yield for obscure gastrointestinal bleeding and abdominal pain was 58.8%. The purpose of DBERC was achieved in 76.9% of procedures. The overall complication rate in our series was 5.4% (1.9% with the DBERC cases removed); in patients under 10, it was 10.4% (7/67). No severe complications associated with enteroscope insertion and sedation were observed. Serum amylase levels tended to be elevated in patients who underwent oral-route DBE. Conclusions: DBE is safe and feasible for diagnostic evaluation of small bowel disorders in pediatric patients, even those younger than 10 years. Special attention for possible complications must, however, be paid during therapeutic DBE procedures, including DBERC, especially for patients under 10.

Management of blunt pancreatic trauma in children

Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury is the fourth most common solid organ injury, following injuries to the spleen, liver and kidneys. The most common complications are the formation of pancreatic fistulae, pancreatitis and the development of pancreatic pseudocysts, which usually present several weeks after injury. The nonoperative management of minor pancreatic injury is well accepted; however, the treatment of more serious pancreatic injuries with capsular, ductal or parenchymal disruption in pediatric patients remains controversial. Based on the data presented in this literature review, although children with pancreatic injuries (without ductal disruption) do not appear to suffer increased morbidity following conservative management, patients with ductal disruption may benefit from operative intervention.

A new operative strategy for refractory microcystic lymphangioma

The optimal management of microcystic lymphatic malformations (LMs) in children has not been established. We describe how we used the Ligasure™ Vessel Sealing System (LVSS) to achieve partial resection of refractory microcystic LMs in a 1-year-old boy. The child was admitted in respiratory distress caused by infection and swelling of cervical LMs. The LMs had been diagnosed prenatally, but had not decreased in size despite three treatments with OK-432 sclerotherapy. We performed direct dissection of the microcystic LMs using the LVSS with minimal intraoperative blood loss or lymphatic leakage. The LMs were resected as completely as possible without damage to the jugular vein or major nerves. His postoperative course was uneventful. Histological examination revealed complete sealing of the lymphovascular channels with obliterated lumens. Resection using the LVSS is effective and easy to perform for partial resection of microcystic LMs. We recommend the combination of initial OK-432 injection therapy and subsequent partial resection using the LVSS for refractory microcystic LMs.

The efficacy of double-balloon enteroscopy for intrahepatic bile duct stones after Roux-en-Y hepaticojejunostomy for choledochal cysts

IntroductionIntrahepatic bile duct (IHBD) stones are one of the most complicated morbidities that occur after Roux-en-Y hepaticojejunostomy (RYH); however, the optimal therapeutic approach is controversial.MethodsDouble-balloon enteroscopy (DBE) has been widely and frequently performed even in pediatric patients. We herein report the successful management of IHBD stones by biliary lithotripsy using DBE after RYH for a choledochal cyst (CC). DBE has made it possible to perform endoscopic therapeutic intervention, including balloon dilatation of an anastomotic stricture and removal of IHBD stones, without any major complications.ConclusionDBE is a less invasive and safe treatment method for IHBD stones in pediatric patients, which is capable of reaching the bilioenteric anastomosis after RYH for CC.

A novel diagnostic and treatment strategy for small intestinal lesions in children: hybrid treatment using transumbilical minimal incision surgery combined with double-balloon enteroscopy

IntroductionDouble-balloon enteroscopy (DBE) is a useful and feasible modality for evaluating small intestinal lesions, even in children.MethodsDBE makes it possible to perform biopsy, diagnosis, polypectomy and endoscopic therapies including hemostasis, tattooing and clipping of the small intestinal lesions. However, endoscopic procedures in the small intestines of children are more difficult than in adults, because the intestinal wall is thin and the lumen is narrow. A novel hybrid treatment was developed using DBE for small bowel lesions combined with transumbilical minimal incision surgery.ConclusionThis hybrid treatment is safe, effective, provides excellent cosmetic results and can be used as an alternative for traditional open laparotomy or endoscopic surgery.

Management of laryngotracheal stenosis in infants and children: the role of re-do surgery in cases of severe subglottic stenosis

Although many advances have improved the treatment of congenital and acquired laryngotracheal stenosis in children over the past two decades, the therapeutic decision-making process remains challenging for pediatric surgeons and otolaryngologists. Severe subglottic stenosis is a complex laryngeal injury that necessitates multiple airway procedures, and the approach depends on the exact nature of the cicatricial lesion and its effect on the vocal cord mobility. Therefore, it is imperative that the pediatric surgeons and otolaryngologists dealing with this situation should be well trained in endoscopy and laser treatment, in addition to open surgical intervention. Open re-do surgery remains the best choice in cases of severe congenital stenosis, glottic immobility, or after two to three endoscopic procedures have been performed without any significant improvement.

Mesenchymal hamartoma of the bilateral chest wall in neonates

A mesenchymal hamartoma of the chest wall is a rare benign tumor. Each case has a different clinical course as well as different radiological imaging findings, and various histopathological diagnoses. In addition, mesenchymal hamartoma is sometimes mistaken for a malignant tumor. This report presents a neonatal case of mesenchymal hamartoma of the bilateral chest wall.

Surgical Management of Duplication of the Pituitary Gland-Plus Syndrome With Epignathus, Cleft Palate, Duplication of Mandible, and Lobulated Tongue.

A 1-day-old male infant was referred to our department for evaluation of multiple malformations in his oral cavity. He was diagnosed duplication of the pituitary gland-plus syndrome with epignathus, cleft palate, duplication of the mandible, and a lobulated tongue. A thumb-sized mass lesion was visible on the hard palate. The duplicated mandible and lower lip was fused at the midline. The alveolar ridge was protruding through a wide-cleft soft palate involving the uvula. Further examination showed a lobulated tongue, which was seen behind the duplicated part of the mandible. Five days after birth, tracheotomy and epignathus resection were performed. At 7 months of age, the excess tissue of the duplicated mandible was resected at the area of adhesion on the lingual side, and the duplicated tongue and lip were reconstructed. A palatoplasty was performed at 20 months of age. Thereafter, the patients progress was uneventful, with no abnormality in swallowing. No recurrence of epignathus has been observed during 2 years of follow-up.

Biodegradable polydioxanone stent as a new treatment strategy for tracheal stenosis in a rabbit model

PURPOSE Congenital tracheal stenosis (CTS) is a rare condition and difficult to treat. Slide tracheoplasty has unsatisfactory outcomes for severe neonatal symptomatic CTS. This study evaluated the use of biodegradable polydioxanone stents (BD stent) in a rabbit model of CTS. METHODS Tracheal stenosis was induced in female Japanese white rabbits, 9-10weeks old, by direct scraping of the tracheal mucosa with a nylon brush following transverse incision of the trachea (control group, n=4). Seven days later, we incised the trachea again and inserted a BD stent (15×5mm) into the trachea (stent group, n=4). Arterial blood gas analysis was performed twice weekly for 1month after the procedure. RESULTS In the control group, respiratory acidosis arising from ventilatory failure was observed on postoperative days 7-10. Rabbits were sacrificed at 11.5days after scraping. Severe tracheal stenosis resulting from inflammatory granulation was detected in the scraped region in all rabbits. In the stent group, arterial blood gas analysis was normal at 28days after stent insertion. The BD stent maintained patency of the tracheal lumen and prolonged survival for 1month. CONCLUSIONS The use of BD stent represents a promising new treatment method for tracheal stenosis.