Sumi Kudou

Endosurgical procedures for pediatric solid tumors

The aim of this study was to evaluate the advantages and complications of endosurgical procedures for benign and malignant pediatric solid tumors. Endosurgical techniques of biopsy and excision were used for diagnosis and treatment of solid tumors, respectively. Since July 1997, a total of 24 biopsies and 24 excisions have been performed laparoscopically for neuroblastoma (n=24), ovarian solid tumors (n=10) and other tumors. Seventeen biopsies and six excisions were performed for abdominal neuroblastoma, while ten excisions were performed for ovarian tumor. In these patients, the length of the operation, blood loss, time to start postoperative feeding, time to start postoperative chemotherapy and length of hospital stay were evaluated and compared to the those of the open surgery group. Furthermore, intra- and postoperative complications were analyzed in all patients of both groups. The length of the hospital stay and time to start postoperative feeding were significantly shorter in the group of patients who underwent endosurgical procedures for either abdominal neuroblastoma or ovarian tumor when compared to the open procedure group. The time to start postoperative chemotherapy was shorter only in the abdominal neuroblastoma group. The procedure for two patients undergoing endosurgical tumor excision had to be converted to open surgery due to large tumor size. Two weeks after thoracoscopic excision of a dumb bell-type neurofibroma, one patient underwent open repair of the dura mater because of leakage of cerebrospinal fluid. There were no port-site recurrences in any tumor types. Endosurgical procedures for solid tumors are effective and minimally invasive. However, better indicators are needed for their implementation in order to prevent complications and subsequent conversions to open procedures.

Residual fistula after laparoscopically assisted anorectoplasty: is it a rare problem?

PURPOSE Although various urologic complications have been reported after abdominoperineal pull-through and posterior sagittal anorectoplasty for the treatment of high-type imperforate anus, reports regarding complications after laparoscopically assisted anorectoplasty (LAARP) are surprisingly rare. Here, we discuss the potential complications of LAARP. METHODS A retrospective study was conducted of 24 patients treated with LAARP from 2000 to 2006. The clinical and operative records were reviewed. Of the 24 patients, 18 were evaluated postoperatively by screening magnetic resonance imaging (MRI). RESULTS The 24 participants are composed of patients with rectoprostatic urethral fistula (n = 15), rectal agenesis (n = 3), rectovesical fistula (n = 2), rectovaginal fistula (n = 2), and cloaca (n = 2). Defecatory function after LAARP was satisfactory. None of the patients had dysuria or urinary infection postoperatively. Cystic formations posterior to the urethra were demonstrated in 9 of the 18 cases examined by MRI. Postoperative voiding cystourethrography failed to demonstrate the lesion in 6 of 9 patients. The types of imperforate anus in this subgroup were rectoprostatic urethral fistula (n = 7), rectovesical fistula (n = 1), and rectal agenesis without fistula (n = 1). Average cyst diameter was 22 +/- 19 mm. Two patients with large cysts (62 and 42 mm) underwent surgical resection. CONCLUSIONS Although satisfactory fecal continence could be achieved by LAARP, we experienced 2 cases with a large residual fistula that required surgical resection. In addition, screening MRI demonstrated the presence of cystic formations in 9 of 18 patients. We recommend that MRI be performed routinely during follow-up of patients treated with LAARP.

A new technique for treatment of tracheal compression by the innominate artery: external reinforcement with autologous cartilage graft and muscle flap suspension

We report a new technique for treatment of tracheomalacia or tracheal compression caused by the innominate artery, utilized in two patients with neuromuscular disorders. Both cases developed a chest deformity in the setting of severe scoliosis. Computed chest tomography and fiberoptic bronchoscopy showed that the cervical trachea was compressed between the innominate artery and the cervical spine in the setting of deformity of the thoracic cavity. Both patients required prolonged mechanical ventilation prior to the operative procedure. To relieve compression by the innominate artery, the superior mediastinum was exposed by resection of part of the manubrium allowing a greater space, and external stenting of the cervical trachea with a reinforcing autologous cartilage graft and tracheopexy, as well as anterior suspension of the innominate artery with a sternohyoid muscle flap were carried out. Both patients were successfully weaned from prolonged mechanical ventilation. Resection of the manubrium sterni, tracheal stenting with rib segments and use of the strap muscle to elevate the innominate artery off of the trachea offer potential long-term release of airway obstruction.

Laparoscopically Assisted Anorectal Pull-Through for Rectocloacal Fistula

Successful laparoscopically assisted anorectal pull-through combined with simultaneous posterior skin flap vaginoplasty is reported. Case Report: A 13-month-old girl who underwent initial sigmoidostomy at birth presented with a rectocloacal anomaly: a double vagina and intermediate confluence of the urogenital sinus with a high type of rectovaginal fistula. She simultaneously underwent a laparoscopically assisted anorectal pull-through and a posterior skin flap vaginoplasty. After vaginoplasty, the distal rectum was laparoscopically dissected and the rectovaginal fistula was divided. A laparoscopic muscle stimulator 5 mm in diameter showed good contraction of the levator muscles in the pelvic floor. With laparoscopic visualization, a guidewire and a balloon catheter were inserted into the center of the levator muscle sling and muscle complex, and dilation of the pull-through tract was achieved. Rectal pull-through and anastomosis between the rectum and anus were successfully completed. The operation took ...

Thoracoscopic treatment of chylothorax after patch repair of congenital diaphragmatic hernia

Chylothorax is a highly morbid complication that may occur after congenital diaphragmatic hernia (CDH) repair. The incidence of chylothorax in this setting has been reported to be 7% to 27% [1-4]. Factors associated with the development of chylothorax include prenatal diagnosis, extracorporeal membrane oxygenation use, and patch repair [2-4]. In other words, patients with severe CDH are more likely to develop chylothorax. Because of recent advances in perinatal care, there has been an increase in the number of patients with severe CDH who would undergo repair. Accordingly, it can be predicted that the number of cases of chylothorax after CDH repair will increase. Management of chylothorax after CDH repair is controversial. Prolonged chest tube drainage for chylothorax can be done; but there is an infection risk, especially in the presence of a sutured prosthetic patch. We present a case of chylothorax after patch closure for CDH, which was successfully treated through the thoracoscopic approach. A newborn who had been prenatally diagnosed with left CDH at 20 weeks gestational age (GA) was delivered by cesarean birth at 37 weeks GA with a birth weight of 2434 g. The baby was intubated immediately after birth, and intensive respiratory care using high-frequency oscillatory ventilation and inhaled nitric oxide was started. After 1 week of stabilization using gentle ventilation and permissive hypercapnea, CDH repair was performed. A small extralobar pulmonary sequestration was found at the edge of the defect and removed. The large defect containing herniated stomach, intestines, spleen, and left lobe of the liver was repaired using a prosthetic Gore-Tex (WL Gore and Associates, Flagstaff, AZ) patch. The patch was sutured using horizontal mattress sutures with pledgets. Postoperatively, the patient had an improved cardiopulmonary status; and inhalation of nitric oxide was terminated on postoperative day 11. After feeding of maternal milk via a nasogastric tube was started on postoperative day 19, an expanding pleural effusion was noted in the left thorax. Aspiration of the pleural effusion revealed chylothorax.

Type I biliary atresia without extrahepatic biliary cyst

Currently, magnetic resonance cholangiography (MRC) is used for the differentiation of biliary atresia (BA) from other causes of infantile cholestasis. The authors present a case of type I BA without an extrahepatic biliary cyst in a 2-month-old girl. MRC clearly visualized the patency of the gallbladder, cystic duct, and hepatic ducts with disappearance of the common bile duct. Intraoperative cholangiography demonstrated a cloudy appearance of the intrahepatic bile ducts, confirming the diagnosis of type I BA. We believe that this is the first reported case of type I BA without an extrahepatic biliary cyst diagnosed by MRC.

Laparoscopic Pyloromyotomy for Infantile Hypertrophic Pyloric Stenosis

Purpose: To evaluate the advantages and disadvantages of laparoscopic pyloromyotomy (LP) compared to the open conventional right upper-quadrant approach for pyloromyotomy (RP), and the umbilical approach for pyloromyotomy (UP). Methods: Clinical records of 175 RP (1983-1994), 71 UP (1994-1997), and 98 LP (1997-2002) were evaluated retrospectively. Weight at birth, age and weight at surgery, blood base excess (BE) on admission, length of operation, complications, and post-operative length of stay were compared among the groups. Results: There were no significant differences in either age or weight among the three groups. The length of operation in the RP group was 29 ± 8 min, which was significantly shorter than that in the UP (40 ± 10 min) and LP (41 ± 14 min) groups. The average length of operation in LP for each surgeon decreased once the surgeon had performed more than 5 LPs. Length of stay was significantly shorter in LP (4.3 ± 1.1 days) than in RP (8.3 ± 4.0 days) and UP (8.7 ± 7.8 days). There were ...

Omental pseudocyst formation associated with perforated gastric duplication: a case report

We present a case of omental pseudocyst associated with a perforated gastric duplication. A boy (2.5 years old) with an abdominal mass was admitted because thick-walled and thin-walled double cysts were identified on computed tomography and magnetic resonance imaging. At laparotomy, the double cysts were interconnected and located in the omentum with no communication to the stomach. Microscopic examination showed a thick-walled cyst composed solely of gastric tissue with muscle layers divided at the stricture between the 2 cysts and a thin-walled cyst without a true endothelial lining. Gastric duplications can be complicated with perforation and malignancy, and primary surgery is the first choice of treatment.

Laparoscopic Resection of Pulmonary Sequestration in an Infant with Congenital Diaphragmatic Hernia

Laparoscopic repair (LR) of late-onset congenital diaphragmatic hernia (CDH) is not a common procedure in infants. We report a successful LR of a left CDH combined with laparoscopic resection of an extralobar pulmonary sequestration. A 4-month-old infant was incidentally diagnosed with left CDH from a chest x-ray. After detailed imaging studies, LR was performed with one optical trocar and three working trocars. Laparoscopy revealed a left CDH with a sac and intestinal herniation. Subsequently, the hernia contents were reduced and the hernia sac was excised by laparoscopic coagulation shears. Laparoscopy also revealed an extralobar pulmonary sequestration and a small lung in the left thoracic cavity. The sequestration was resected using a GIA stapler, and the defects of the diaphragm were directly sutured using nonabsorbable sutures. The patient had an uneventful recovery following a short hospital stay. Conclusion: The laparoscopic approach can be an effective and more advantageous alternative to laparot...