Shinya Takazawa

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.

Differences in the characteristics and management of pyriform sinus fistula between neonates and young children

PurposePyriform sinus fistula (PSF), which originates from the third or fourth branchial pouch remnant, is relatively rare. In young children and adults, it is characterized by lateral neck infections and suppurative thyroiditis, while neonatal PSF presents as a large cervical cystic mass and causes respiratory distress. We hypothesized that the characteristics and management of PSF may differ between neonates and young children.MethodsHospital case records of the neonatal group and the young children’s group presenting between January 2002 and December 2010 were retrospectively reviewed. We analyzed differences in the presenting symptoms, diagnostic images, and operative findings between the groups.ResultsTwelve patients (5 males and 7 females) of PSF were identified. In neonatal PSF, the orifice of the pyriform sinus was commonly wide, with a large cyst, readily enabling the insertion of a guide wire. In young children, PSF caused cervical pain and suppurative thyroiditis, and the opening of the fistula was relatively small. Supportive cannulation was not easily performed.ConclusionThere are distinctive etiological differences between the neonatal and young children’s groups. In the case of unsuccessful supportive cannulation, direct visualization of the pyriform fossa is a useful procedure for complete resection of PSF, with incision of the inferior pharyngeal constrictor muscle.

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.

Successful two-stage thoracoscopic repair of long-gap esophageal atresia using simple internal traction and delayed primary anastomosis in a neonate : report of a case

The optimal method of treating long-gap esophageal atresia has not been established; however, the native esophagus is recognized as one of the best materials to use for bridging a long gap. Several case reports describe long-gap esophageal atresia being treated successfully via thoracotomy, by applying external traction sutures to the proximal and distal ends of the esophagus, thereby gradually elongating the esophagus prior to delayed primary anastomosis. However, this method carries a risk of infection and disruption of the esophageal ends. We devised a simple method of internal traction for esophageal elongation, which we performed as a two-step thoracoscopic procedure to treat a neonate with long-gap esophageal atresia.

Quantitative pediatric surgical skill assessment using a rapid-prototyped chest model.

Abstract Introduction: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed. Material and methods: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup. Results: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model. Conclusion: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Development of a Needle Driver with Multiple Degrees of Freedom for Neonatal Laparoscopic Surgery

AIMS The aims of this study were to develop a thin needle driver with multiple degrees of freedom and to evaluate its efficacy in multidirectional suturing compared with a conventional needle driver. MATERIALS AND METHODS The tip (15 mm) of the novel user-friendly needle driver (3.5 mm in diameter) has three degrees of freedom for grasping, rotation, and deflection. Six pediatric surgeons performed two kinds of suturing tasks in a dry box: three stitches in continuous suturing that were perpendicular or parallel to the insertion direction of the instrument, first using the novel instrument, then using a conventional instrument, and finally using the novel instrument again. The accuracy of insertion and exit compared with the target points and the procedure time were measured. RESULTS In the conventional and novel procedures the mean gaps from the insertion point to the target in perpendicular suturing were 0.8 mm and 0.7 mm, respectively; in parallel suturing they were 0.8 mm and 0.6 mm, respectively. The mean gaps from the exit point to the target in perpendicular suturing were 0.6 mm and 0.6 mm for conventional and novel procedures, respectively; in parallel suturing they were 0.6 mm and 0.8 mm, respectively. The procedure time for perpendicular suturing was 33 seconds and 64 seconds for conventional and novel procedures, respectively (P=.02); for parallel suturing it was 114 seconds and 91 seconds, respectively. CONCLUSIONS Our novel needle driver maintained accuracy of suturing; parallel suturing with the novel driver may be easier than with the conventional one.

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.

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.