Tadao Okada

Optimal strategy of preoperative transcatheter arterial chemoembolization for hepatoblastoma.

PurposeTo investigate the optimal strategy of preoperative transcatheter arterial chemoembolization (TACE) for hepatoblastoma.MethodsBetween 1992 and 2001, 7 children with hepatoblastoma (aged 9 months to 13 years) underwent preoperative TACE. The chemoembolic agent used was an emulsion of pirarubicin and lipiodol. Four patients without distant metastasis underwent “primary” TACE without systemic chemotherapy. The other 3 with distant metastases underwent “delayed” TACE following systemic chemotherapy. These patients were all examined retrospectively using clinical data.ResultsThe average dosage of lipiodol was 0.6 ml per tumor maximal diameter (cm). All the primary cases showed a significant decrease in α-fetoprotein (AFP) and a reduction in the tumor size. They consequently underwent a complete surgical resection and are now disease free. All the delayed cases showed a slight decrease in AFP and underwent complete surgical resection; however, two of them died of lung metastases, and the other died of a second malignancy. Regarding complications, liver dysfunction and pulmonary embolism occurred in one patient each.ConclusionsFor patients without distant metastasis, regardless of the resectability of the primary tumor, TACE may be considered the initial and only preoperative treatment, and it may be repeated. For patients with distant metastases, their complete eradication with systemic chemotherapy prior to TACE is essential.

Management of blunt hepatic injury in children: usefulness of emergency transcatheter arterial embolization.

Abstract.We reviewed our experience to determine the usefulness of emergency transcatheter arterial embolization (TAE) for severe blunt hepatic injury (BHI) in children. Between 1978 and 2000, 21 children with BHI (14 boys and 7 girls, ranging in age from 2 to 14 years) were managed according to our protocol. The patients who were hemodynamically stable, and had no other associated injury requiring laparotomy, regardless of the hepatic injury grade, were managed nonsurgically. Emergency angiography and TAE performed after a CT scan revealed extravasation of the contrast medium. Of the 21 patients, 3 underwent emergency laparotomy; 2 due to hemodynamic instability despite fluid resuscitation (1 died), and the 3rd patient because of associated injury. The other 18 patients (86%) were initially managed nonsurgically; however, 2 underwent delayed laparotomy because of complications (1 each of suspected delayed hepatic hemorrhage and liver abscess). Nonsurgical management was completed in the remaining 16 (89%) with no morbidity and mortality. Two of the 16 returned to a hemodynamically stable condition with fluid resuscitation, but were compromised with persistent hepatic hemorrhage, and were successfully treated with emergency TAE. We propose that emergency TAE should be considered as an initial treatment for severe BHI in children.

Strangulated umbilical hernia in a child: report of a case.

Abstract Most umbilical hernias in children close spontaneously. Complications associated with umbilical hernias are rarely observed during follow-up. We report herein a 5-month-old girl with a strangulated umbilical hernia. Her umbilicus was hard, reddish, and irreducible. Plain radiography of the abdomen showed signs of mechanical ileus. The patient was thus diagnosed to have a strangulated umbilical hernia. A 5-cm section of the ascending colon and a 5-cm section of the terminal ileum, as well as the cecum and appendix, were congested, edematous, and erythematous, and together were enclosed by a firm hernial ring. A closure of the fascial defect and umbilicoplasty were performed. The postoperative course was uneventful. In patients with infantile umbilical hernias, strangulation may occur as the fascial defect decreases in size.

Effective endless-loop bougienage through the oral cavity and esophagus to the gastrostomy in corrosive esophageal strictures in children

The authors present a safe, conservative method of endless-loop bougienage (ELB) through the oral cavity and esophagus to a gastrostomy without general anesthesia in three children with corrosive esophageal burns treated since 1966. Esophagogastroscopy was performed to evaluate for esophagitis at an early phase after ingestion of the caustic substance. When esophageal stricture formation was recognized after subsequent conservative treatment, a feeding gastrostomy was made. A continuous string loop with plummets of progressively larger size was positioned to pass through the patients oral cavity and esophagus to the gastrostomy. Strictures were found in the upper esophagus in two patients and in the middle and lower esophagus in one. The gastrostomy was performed 15␣months, 20 days, and 2 months after the injury, respectively, and the periods of ELB were 3, 5, and 2½␣years, respectively. The patients were able to start eating at 26, 42, and 29 months after injury, respectively. They are now 30, 18, and 17 years old, and slight dysphagia remains in patients 1 and 2. No patient developed esophageal carcinoma at the site of the corrosive stricture. Our method of ELB through the patients oral cavity and esophagus to the gastrostomy appears to be safe, reliable, and useful. We believe that most caustic esophageal strictures in children can be treated by this conservative measure.

Extirpation of mass-screened adrenal neuroblastomas by retroperitoneoscopy

Background: A mass-screened neuroblastoma (MSN) shows low-grade malignancy. Although the tumor is small, open laparotomy requires a large incision. Purpose: Extirpation by retroperitoneoscopy (ER) was performed in children with MSN to reduce the surgical stress. Methods: The indications for ER were (1) MSN originating from the adrenal gland and (2) a tumor size of less than 4 cm. Between January 2000 and June 2002, 6 children (mean age: 8.5 ± 0.6 months) underwent ER. Results: All children successfully underwent ER and no conversion of laparoscopy to open surgery was required. The only complication in one patient was a peritoneal tear. Oral intake was possible in all children the day after the operation. No port site metastasis or local recurrence was observed during follow-up (15 to 29 months). Conclusions: Adrenal MSN less than 4 cm were successfully extirpated by ER. This method has the advantage of allowing patients an early return to eating and has no risk of postoperative ileus. ER is an available surgical technique for children with MSN less than 4 cm.

Endoscopic internal biliary drainage in a child with malignant obstructive jaundice caused by neuroblastoma

Abstract. We describe a 13-year-old girl who underwent insertion of a Flexima biliary stent for obstructive jaundice due to compression of the extrahepatic bile duct by an enlarged lymph node secondary to neuroblastoma. This novel endoscopic internal biliary drainage procedure was safe and effective even for a child, and improved her quality of life. We further review other treatment options available for malignant obstructive jaundice in children.

Long-term survival in a patient with congenital laryngeal atresia and multiple malformations.

Abstract Laryngeal atresia (LA) is an uncommon congenital anomaly, and only a few cases with long-term survival are reported in the literature. The authors describe a 2-year-old boy with LA and esophageal (EA), intestinal, and urethral atresia (UA). Immediately after birth, severe respiratory distress and mild abdominal distension became evident. Endotracheal intubation was unsuccessful and emergency tracheal puncture was performed, after which a tracheostomy was constructed. Direct laryngoscopy revealed LA at the vocal cord level. A cystostomy and gastrostomy were constructed immediately because of UA and EA. A cystocutaneostomy, ileocolic anastomosis, and resection of a tracheoesophageal fistula (TEF) were simultaneously performed 1 day after birth. The EA was proximal with a distal TEF. The gap between the ends of the upper and lower esophagus was 4 cm in length. It was thought impossible to perform a primary anastomosis, and therefore, a gastrostomy and resection of the TEF using multiple-stage surgery was undertaken. Intestinal resection and anastomosis were performed due to intestinal stenosis from necrotizing enterocolitis at the age of 3 months. Hypoxic encephalopathy developed due to accidental obstruction of the tracheostomy tube at the age of 10 months, and physical therapy was begun. He required a cutaneous nephrostomy due to a right hydromegaureter with vesicoureteric reflux and a left non-functioning kidney at the age of 23 months. He has been hospitalized for partial ventilatory assistance for 2 years at our institution. The course of this patient seems noteworthy in relation to the genesis of the multiple malformations.