The risk of acute abdomen in neonates and infants is generally increased due to advanced maternal age and neonatal intensive care unit care development. Enterostomy is a safe procedure for acute abdomen in neonates and infants. However, there is no consensus for the optimal timing of enterostomy closure (EC). A few considerations should be reviewed for deciding the timing of stoma closure to obtain the best outcome. Distal loopography is commonly performed upon examination to ascertain the existence of a distal passage after EC, detect signs of disease-specific complications, and assess the need of surgery in addition to EC. Pathology review is also one important pre-closure consideration. When the incidence of a hypoganglionosis or an aganglionosis combined with acute abdomen is observed in neonates and infants, thorough examinations should be performed to conclusively determine whether there is no passage disturbance of the distal bowel. Refeeding not only provides information about chance to grow, electrolyte imbalance correction, and proximal and distal bowel size match, but also provides information about distal bowel passage when there is a doubtful distal loopography or pathology result. Early closure enables growth spurt with the correction of water/electrolyte imbalance. It potentially reduced medical costs, less discrepancy between proximal and distal bowel size. Some factors favoring a late stoma closure may be due to less postoperative complications, early recovery, shorter time of total parenteral nutrition after EC, and decreased length of hospitalization after the EC. Some studies have shown controversial results. In summary, a pre-closure evaluation is imperative to assure the safety of an EC. The optimal timing of an EC remains controversial. For this reason, individualized approach is needed after reviewing the general condition of each patient. Further prospective study on optimal timing of stoma closure including a randomized clinical trial is needed.
Single-port laparoscopy-assisted surgery is being performed for various operations in pediatric patients recently. The aims of this study were to prove the safety and find well-matched indications of small bowel resection using single-site umbilical laparoscopic surgery (SSULS).
From 2011 to 2016, 29 pediatric patients underwent SSULS. Medical records were retrospectively reviewed.
A total of 29 patients were included and 30 SSULS were performed in this study. The mean age at operation was 5.7 years, and the mean weight was 21.9 kg. Meckel's diverticulum was the most common indication for SSULS, followed by small bowel intussusception due to leading point mass, small bowel duplication, and Crohn's disease. In most cases, estimated blood loss was negligible except in Crohn's disease with severe inflammation. While answering post-discharge questions about scars, most parents responded that they were satisfied with the postoperative wound.
SSULS is a useful operation to try even for surgeons who do not have advanced laparoscopic skills. Complication rates of single-port operations do not differ from those of conventional laparoscopic operations. Most lesions of the small bowel could be indications of SSULS. Careful attention is required when performing SSULS in patients with Crohn's disease.
This study aimed to evaluate the relationship between nutritional support and growth velocity after abdominal surgery in neonates.
The electronic medical records of 45 neonates who underwent abdominal surgery in neonatal intensive care unit from 2012 to 2016 were collected to see how surgery and postoperative nutrition affect for the growth of neonate with abdominal surgery. The growth velocity was measured from the time of surgery to the time of discharge based on body weight.
In neonates who achieve their protein requirement on the first day after surgery, the growth velocity was better than that in neonates who did not achieve their protein requirement on the first day after surgery (4.31 vs. 15.21; p=0.004). Based on the type of surgery, length of bowel resection and surgical complications, this study showed better growth velocity in neonates who had no surgical complications (5.34 vs. 12.74; p=0.775), reoperation (5.25 vs. 22.19, p=0.987), or bowel resection (6.79 vs. 9.95, p=0.302). However, there was no statistically significant difference among these factors.
We concluded in this study that adequate protein supplement from the first day of surgery could have a positive effect on the growth velocity of neonates who underwent abdominal surgery.
Lymphatic malformations are benign congenital malformations of the lymphatic system that occur predominantly in children. Most lymphatic malformations occur in the head and neck region, with those in abdominal locations, such as the mesentery, omentum and retroperitoneum, being less common, accounting for fewer than 5% of lymphatic malformations in children. This study analyzed the clinicopathologic characteristics and treatment outcomes of abdominal lymphatic malformations in children.
The medical records of 12 pediatric patients treated for abdominal lymphatic malformations at our institution between April 1999 and September 2017 were retrospectively reviewed. Demographic and clinical characteristics, including gender, age, symptoms and signs, diagnostic modalities, and treatment results, were analyzed.
The 12 patients included 11 boys and 1 girl, ranging in age from 3 months to 17 years (median 36.5 months) at presentation. The primary signs and symptoms included abdominal pain, abdominal mass and abdominal distention. Other symptoms and signs included fever, vomiting, scrotal pain and mass, and right inguinal mass. All patients were diagnosed by abdominal ultrasonography and computed tomography, and all underwent surgical excision with or without bowel resection. The lymphatic malformations occurred in the retroperitoneum (n=4), omentum (n=4), jejunal mesentery (n=2), and retroperitoneum and mesentery (n=2). Seven patients underwent complete mass excision, including 3 who underwent laparoscopic excisions, and 3 who underwent mass excision with segmental resection of the adjoining bowel. Two patients underwent incomplete excision because the lesion was extensive and invaded the superior mesenteric vessels. There was no major perioperative morbidity in any patient. At a median follow-up of 50 months (range, 8–183 months), only 1 patient experienced recurrence.
Although abdominal lymphatic malformations are benign, most children present with acute abdominal symptoms, necessitating early surgical treatment.
We describe our experience in managing congenital diaphragmatic hernia (CDH) in neonates.
From February 1995 to July 2014, 64 neonates diagnosed with CDH were managed. The medical records of these neonates were retrospectively reviewed.
There were 40 males and 24 females. CDH was on the left side in 44 cases (68.8%), on the right side in 19 cases (29.7%) and bilateral in 1 case (1.6%). Forty-six patients (71.9%) received surgical repair of the hernia while 18 patients (28.1%) died prior to surgery. The timing of surgery was mean 7.0 days after birth. Extracorporeal membrane oxygenation was used in six patients (9.4%), High-frequency oscillation ventilation was used in 49 patients (76.6%), and nitric oxide was used in 42 patients (65.6%). Thirty-three cases (71.7%) of CDH repair were done via open laparotomy, 3 cases (6.6%) by open thoracotomy. and minimally invasive thoracoscopic repair was done in 10 cases (21.7%). Ten cases (21.8%) required patch repair of the CDH. Barotrauma and pneumothorax of the contralateral lung was seen in 16 cases, leading to death in 15 of these cases. The overall survival rate was 48.4% (31/64) and postoperative survival rate was 67.4% (31/46). When all patients are divided into 3 groups by era and analyzed by logistic regression models, the mortality outcome of recent era (2009–2014) was significantly better than that of intermediate era (2002–2008) (29% vs. 71%, p=0.006) and tended to be better than that of past era (1995–2001) (42% vs. 71%, p=0.062).
The overall survival of neonates with CDH at our center has improved over the last two decades. Sixty-four neonates with CDH were managed at a single center and their overall survival was 48.4%. The risk factors for mortality include the occurrence of pneumothorax and right side lesions.
We evaluated perioperative and long-term outcomes of minimally invasive surgery (MIS) and established indications of MIS in solid pseudopapillary tumor (SPT) in pediatric patients.
From October 1992 to April 2018, 66 patients (age, <18 years) diagnosed with SPT underwent either open pancreatectomy (OP) or MIS. Variables including postoperative complications and recurrence rates were retrospectively analyzed.
Thirty-five patients underwent open surgery and 31 underwent laparoscopic/robotic surgery. Mean tumor size in MIS was significantly smaller than that in OP (4.3±1.8 cm vs. 7.6±3.5 cm, p=0.005). There were 4 cases of open conversion from laparoscopic surgery because of vessel encasements (n=2), bleeding (n=1), and pancreatic ductal injury (n=1). Solitary pseudopapillary carcinoma was diagnosed in 6 patients. Recurrence was observed in 3 and 1 patients who underwent OP and MIS, respectively (p=0.634). Tumor size, mass size/abdominal diameter (MS/AD) ratio, and degree of the portal or superior mesenteric vein involvement were the most important indications for MIS.
MIS is being widely used in pediatric surgeries with increased expertise and safety, especially in pancreatic diseases. Careful patient selection for MIS in regards with parameters such as MS/AD ratio and vessel abutment might be a feasible choice.
Total proctocolectomy with ileal pouch-anal anastomosis (T-IPAA) in childhood is a surgical procedure mainly applied to familial adenomatous polyposis (FAP) or ulcerative colitis (UC), but it can be applied to non-FAP/non-UC disease (NFNU). Studies regarding the role of T-IPAA who underwent the operation in childhood, especially in terms of long-term gastrointestinal function, complications, and quality of life (QOL) are limited. The aim of this study was to evaluate the characteristics of patients receiving T-IPAA and to compare their bowel function outcomes and QOL.
Patients aged ≤18 years at the time of T-IPAA were included. Their medical records were retrospectively reviewed. Krickenbeck classification, Cleveland Clinic Incontinence (CCI) score, 36-item Short-form Health Survey Questionnaire, and Gastrointestinal Quality of Life Index were used for the evaluation of bowel function and QOL. The median follow-up period was 9.8 years.
Of the 25 patients, 9 had FAP, 9 had UC, and 7 had NFNU. NFNU include 3 of Hirschsprung disease, 2 of intestinal neuronal dysplasia, and 2 of imperforate anus. The median age at T-IPAA was 17.8, 14.2, and 9.3 years for FAP, UC, and NFNU, respectively (p=0.001). Bowel function was satisfactory in terms of voluntary bowel movement (VBM), soiling, and constipation. VBM and constipation were not different between the groups, but soiling was most in NFNU (100%, p=0.047). However, QOL was best in the NFNU group in surveys (p=0.034 and 0.004, respectively).
T-IPAA could be safely applied not only for FAP and UC but also for other diseases in selective cases, with caution.
We present an extremely rare case with double H-type tracheoesophageal fistulae identified with a time-lapse and repaired separately. A newborn male presented with cyanosis after breastfeeding. Contrast esophagogram demonstrated an H-type fistula, and then it was repaired in a standard fashion via right thoracotomy. When routine esophagogram was taken on postoperative day 10, another fistula was noticed at a level higher than the previous one. Bronchoscopy was performed to evaluate the lesion whether it was a recurred fistula or a second H-type fistula. However, it was so tiny that it was not visible with bronchoscopy. It was discovered only two months later when the fistula had grown up with the baby. The second H-type fistula was repaired through a cervical incision. Although double H-type fistulae are extremely rare, the possibility of another fistula, as well as recurrence, must be ruled out when symptom recurs after a definitive operation of an H-type fistula.
Early suspicion is essential in diagnosing pyriform sinus cysts. We report two neonatal cases of pyriform sinus cysts presented as neck masses. The first case presented as a right neck mass, which made it more difficult to suspect a pyriform sinus cyst considering the prevalence of left sided cysts. Surgical resection was done in both cases and anatomical investigation suggested both to originate from the fourth branchial pouch. Detection of air bubble containing mass on imaging studies can aid early diagnosis and early use of gastric tube feeding can facilitate treatment by preventing milk contamination which may result in infection of the sinus cyst.
Although gallbladder (GB) hydrops in childhood is uncommon, it is most commonly associated with Kawasaki disease (KD) and can be a risk factor of poor outcomes in patients with KD. Our patient presented with a fever, diffuse abdominal pain, maculopapular rash, bilateral conjunctivitis, red and fissured lip tissue, and 3 days of right cervical swelling. Abdominal examination revealed abdominal distension and tenderness. Abdominal ultrasonography was performed to identify the source of abdominal symptoms, which revealed dilatation of the GB. Abdominal computed tomography scan was also performed to exclude other hepatobiliary disease, which showed normal hepatobiliary systems. The GB of our patients returned to a normal size without any complications, but it regressed very slowly. We report a case of a 6-year-old boy with KD who presented with markedly distended and unusually prolonged GB hydrops.
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