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Volume 7(2); December 2001

Original Articles

[English]
Biliary atresia (BA) is very difficult to distinguish from neonatal hepatitis (NH) and its prognosis depends on the age at the time of Kasai operation. Therefore early differentiation between these two conditions is very important. Although various clinical and laboratory tests have been reported to differentiate between them, they are still of limited value. From 1980 to 1999, forty-five infants were referred to our pediatric surgical unit for operation for suspected BA. Eight patients underwent Kasai operation immediately because late diagnosis. These were excluded from the study. The clinical history, physical findings, radiologic and laboratory examinations of 37 cases were analyzed retrospectively. The average age of BA (n=20) was 55.1+/-6.7 days, and that of NH (n=17) was 55.8+/-5.6 days. The sex ratio of BA was 13:7, and that of NH was 14:3. All the patients had obstructive jaundice and acholic stool except 4 BA and 6 NH patients. Acholic stool with yellow component was more frequent in NH. Onset of jaundice was within 2 weeks after birth in 85% of BA, and in 65% of NH. The onset of acholic stool was within 2 weeks after birth in 60% of BA, and in 23.5% of NH. The duration of jaundice and acholic stool of BA were 50.9+/-6.6 days and 41.3+/-8.4 days and those of NH were 40.1+/-3.1 days and 26.6+/-5.4 days respectively. The ultrasonogram and hepatobiliary scan were useful, but not a definitively reliable method for the differentiation of these two diseases. There was no difference in laboratory data. Seventeen cases had NH among 45 referred cases for Kasai operation with the clinical impression of BA, and 4 cases of 17 NH cases needed to be explored to rule out BA. In conclusion, false positive rate of clinical impression of BA was 37.8%, and negative exploration rate was 8.9%. Therefore, careful clinical observation for 1-2 weeks by an experienced pediatric surgeon was very important to avoid unnecessary operation to rule out NH up to the age of 8 - 10 weeks, so long as the stool had yellow component.
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[English]
To investigate the diagnostic accuracy and applicability of barium enema (BE) and rectal suction biopsy with acetyl cholinesterase (AChE) histochemistry in the diagnosis of neonatal Hirschsprung's disease (HD), we retrospectively reviewed the findings of BE and AChE staining in 96 neonates with suspected HD during a 10-year period from January 1991 to December 2000. Sixty-nine cases of HD (58 males and 11 females) and 27 cases of non-HD are included in this study. In regard to BE, HD was based on definite transitional zone, suspicious HD on reversed rectosigmoid index (RSI <1), and non-HD on normal RSI (RSI>1). The histochemical criterion used for the diagnosis of HD was that of Chow et al (1977), i.e., the presence of many coarse discrete cholinergic nerve fibers in the muscularis mucosae and in the immediately subjacent submucosa regardless of infiltration of cholinergic nerve fibers in the lamina propria. Of 66 neonates with HD who underwent BE, transitional zone was identified in 33 cases (50%) and reversed RSI in 19 cases (21%), microcolon in 4 cases and normal finding in 10 cases (15%) while of 27 neonates with non-HD, there was normal finding in 16 cases and reversed RSI in 9 cases (41%). Thus diagnostic accuracy based on transitional zone was 64%. The positive predictive value of reversed RSI for the diagnosis of HD was 68%. Of 42 neonates with HD who underwent AChE histochemistry, there were 41 AChE-positive reactions and one AChE-negative reaction in a neonate with total colonic aganglionosis, while of 27 cases of non-HD, there were one equivocal AChE-positive reaction and 26 AChE-negative reactions. Thus AChE histochemical study showed a 97% diagnostic accuracy with a 98% sensitivity and a 96% specificity. In conclusion, we believe that BE is valuable as a first diagnostic step since about 80% of neonates with HD show significant radiologic findings such as a transitional zone or reversed RSI. AChE histochemical study was a more reliable diagnostic tool showing a 97% diagnostic accuracy, and is particularly valuable in neonates with HD who showed reversed RSI or normal RSI on BE. A diagnostic algorithm in neonates with suspicious HD was proposed.particularly valuable in neonates with HD who showed reversed RSI or normal RSI on BE. A diagnostic algorithm in neonates with suspicious HD was proposed.
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[English]
Intestinal Perforations in Very Low Birth Weight Infants
Kim, Dae Yeon , Kim, Seong Chul , Kim, Ai Rhan , Kim, Ki Soo , Pi, Soo Young , Kim, In Koo
J Korean Assoc Pediatr Surg 2001;7(2):112-117.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.112
With the advances in neonatal intensive care, pediatric surgeons experience very low birth weight infants, weighing <1,500 g, more frequently. We report our 14 cases of very low birth weight infants with intestinal perforations without congenital causes, at the Asan Medical Center during the 11-year period from 1989 to 2000. The average birth weight was 919 g (563-1,490), and average gestational age was 206 days (161-286). There were nine males and five females. Operation was performed at an average age of 14.0 days (3-38). Ten neonates with symptomatic PDA were given indomethacin in an attempt to close the ductus. Bowel perforation involved the jejunum in two and ileum in twelve. At laparotomy, there were seven focal intestinal perforations, five typical NEC, one intussusception, and an unknown cause. Four neonates underwent resection and anastomosis of the bowel, and nine underwent exteriorization. One underwent resection and anastomosis after peritoneal drainage. Four patients had postoperative complications; two leakage of anastomosis, one stoma necrosis, and one internal herniation. Seven of fourteen patients survived (50.0%). Seven patients died of septic complication. There was a significant difference in the birth weight and gestational age in survivors compared with those who died (p<0.05). There was an increased risk of bowel perforation in indomethacin treatment for PDA. Careful clinical observation and keen judgment are essential for this particular group of infants.
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[English]
Clinical analysis of adhesive ileus in children
Lee, Jong Jae , Youn, Hyun Jo , Jeong, Yeoun Jun , Kim, Jae chun
J Korean Assoc Pediatr Surg 2001;7(2):118-125.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.118
The effectiveness of operative and non-operative management for postoperative adhesive ileus in children has been discussed. This study reviews the clinical characteristics and the treatment consequences of adhesive ileus in our institution, Department of Surgery of Chunbuk National University Hospital, retrospectively. A total of 62 cases of post-operative small bowel obstruction treated between January 1975 and December 1998 under the 15 years of age are included in this study. The patients were divided into two groups, operative (n=26) and non-operative (n=36) groups. The prevalent age was between 11 and 15 years (28 cases; 45.2%), and the most common previous operation was appendectomy (28 cases; 45.2%). The most common operative procedures were adhesiolysis (17 cases; 65.4%). The interval between admission and operation was 1 day in 11 cases (42.3%). The most common site of adhesion was the ileum in 13 cases (50.0%) and band constriction was the most frequent pattern (8 cases; 30.8%). Intestinal resection was significantly high in delayed operations of more than four days, in the patients with three or more classical signs of strangulation (fever, tachycardia, leukocytosis, abdominal pain, rebound tenderness), and in the cases of complete obstruction on plain abdomen film (p < 0.05). In conclusion, operation should be considered in cases with three or more signs of strangulation, no clinical improvement for over four days of conservative treatment, and signs of complete obstruction on plain abdomen film during the observation periods.
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[English]
Leadpoints in Childhood Intussusception
Kwan Ju Lee, Jae Hee Chung, Min Kwang Hong, Won Yong Sung, Chang Hyeok An, Young Tack Song
J Korean Assoc Pediatr Surg 2001;7(2):126-129.   Published online December 31, 2001
DOI: https://doi.org/10.13029/jkaps.2001.7.2.126

Childhood intussusception is usually idiopathic, and pathological lesions as the leading point are found in limited cases. Sixteen operative cases with leadpoints among 2,889 cases of childhood intussusecption treated at the surgical departments of the affiliated hospitals of Catholic University over 19 years are reviewed. The approximate incidence of pathological lesions as the leading point was 0.6%. The male to female ratio was 2:1. The mean age was 3.5 years. There was not an age preponderance. The symptoms were vomiting (63%), abdominal pain (38%), irritability (38%), bloody stools (25%), fever (25%) and abdominal mass (6%). The average duration of the symptoms was 2.4 days (1-10days). The most common lesion was Meckel's diverticulum, followed by malignant lymphomas, polyps, ectopic pancreas, and cecal duplication. An ileocolic type was most frequent, followed by ileoileocolic and ileoileal. Segmental resection or wedge resection of the ileum was done in 10 cases, ileocecectomy in 3, and right hemicolectomy in 3. Surgical reduction was done only in an ectopic pancreas, with no later recurrence. The average hospital stay was 10 days. Postoperative adhesive ileus occurred in two cases, and in one of them adhesiolysis was performed. One case of malignant lymphoma died at 28 days after surgery due to chemotherapy related complication.

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[English]
Short-Term Outcomes of Transanal One-Stage Pull-Through for Hirschsprung's Disease
Gyung Mo Son, Hae Young Kim
J Korean Assoc Pediatr Surg 2001;7(2):130-136.   Published online December 31, 2001
DOI: https://doi.org/10.13029/jkaps.2001.7.2.130

The aim of this study was to evaluate the short-term outcomes of the transanal one-stage pull-through procedure (TOP) in Hirschsprung's disease. Eight patients aged 3 weeks to 8 months with Hirschsprung's disease underwent this procedure. A rectal mucosectomy was performed from just proximal to dentate line to the level of peritoneal reflexion, where muscle layer was incised circumferentially. Rectosigmoid was mobilized out through the anus, and full-thickness frozen biopsy was taken for confirmation of ganglionic cells. After the rectal muscular cuff was divided longitudinally in the posterior aspect, aganglionic bowel was removed and ganglionic colon was anastomozed to the anus. The mean operating time was 161 minutes, and the mean hospital stay after operation was 3.8 days. Five patients had three to four bowel movement per day without other therapy at mean postoperative 39.2 days. Although long-term follow-up will be required, the TOP might be the new alternative surgical procedure for Hirschsprung's disease.

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[English]
Results of Modified Sistrunk Operation in Thyroglossal Duct Cyst: A Review of 81 Cases
Kyeong Geun Lee, Poong Man Jung
J Korean Assoc Pediatr Surg 2001;7(2):137-141.   Published online December 31, 2001
DOI: https://doi.org/10.13029/jkaps.2001.7.2.137

Thyroglossal duct cyst is ectodermal remnant, which may develop along the line of descent of the thyroid gland from the foramen cecum of the tongue to the pyramidal lobe of the thyroid gland. Meticulous dissection of the cyst and duct, along with the body of the hyoid bone is necessary to avoid recurrence. Eighty-one patients with thyroglossal duct cyst treated at Hanyang University Hospital between January 1980 and December 2000 were reviewed to determine the incidence and to analyze the result of management. The male-to-female ratio was 1.4:1 (47:34) with a male preponderance. They are most commonly present at 3-8years (54.2%) of age, but rarely present at infancy. The most common symptom was a painless midline neck mass (76.5%, 62cases). Eighty-one patients underwent modified Sistrunk operation without evidence of recurrence. Eight-nine percent (72 cases) of these lesions were located between thyroid substance and hyoid bone, and 11% (9 cases) were above the hyoid bone. There were 22 infected cysts (27.2%). The Sistrunk operation is a gold standard for treating the thyroglossal duct cysts. For best results in thyroglossal duct cyst surgery, one should make every effort to remove the cyst intact in continuity with the body of the hyoid bone. In our institute, Sistrunk operation modified by the authors showed a good result.

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[English]
OK-432 Intralesional Injection Therapy for Lymphangioma in Children
Kim, Kyung Hun , Kim, Hyun Hahk , Lee, Suk Koo , Seo, Jeong Meen , Chang, Weon Young , Lee, Byung Boong
J Korean Assoc Pediatr Surg 2001;7(2):142-146.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.142
Lymphangioma is a congenital malformation of the lymphatic system, commonly seen in the neck. Operation was the treatment of choice but it is difficult to resect the lymphangiomas completely. The aim of this study is to evaluate the result of intralesional injection of OK-432 as a treatment strategy of lymphangioma in children. Medical records of 51 cases of lymphangioma from March 1996 to February 2001 were reviewed retrospectively. Intralesional injection of 0.1 mg OK-432 in 10ml normal saline was performed after the aspiration of as much fluid as possible. The location of the lesion was the face and neck in 26 patients, the chest wall in 14, the extremities in 9, and the abdominal wall in 2. The cystic type was present in 45 patients and the cavernous type in 6. Four postoperative recurrent cases were included. Fluid aspiration from the lesion was impossible in 5 patients. Development of fever after injection was observed in 27 patients and local inflammatory reaction was in 5 patients. There was no scar formation at injection sites. Complete shrinkage was observed in 20 patients, remarkable shrinkage in 23, slight shrinkage in 3, and no response in 5. Cystic type or aspiration-possible cases showed better outcome than cavernous type or aspiration-impossible cases. All of four recurrent cases after surgical excision showed at least remarkable shrinkage. These results indicate that intralesional injection of OK-432 is a safe and satisfactory treatment modality of lymphangiomas in children and might be considered as a treatment of choice, even in recurrent cases.
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[English]
Index Cases in Pediatric Surgery, 2000: National Survey by the Korean Association of Pediatric Surgeons
Lee, M D , Kim, S Y , Kim, W K , Kim, I K , Kim, S C , Kim, S K , Kim, J E , Kim, J C , Kim, H H , Park, K W , Park, W H , Seo, J M , Song, Y T , Oh, S M , Yoo, S Y , Lee, D S , Lee, S K , Lee, S C , Chung, S Y , Chung, S U , Jung, E S , Jung, P M , Cho, M H , Choi, K J , Choi, S O , Choi, S H , Han, S J , Huh, Y S , Hong, C , Whang, E H
J Korean Assoc Pediatr Surg 2001;7(2):147-156.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.147
Membership qualifications and recognition of the subspecialty training programs by the Korean Association of Pediatric Surgeons (KAPS) have been determined by criteria based on the number of neonatal and total pediatric surgical cases registered, since 1989 (Index cases). The numbers are based on a survey of the 14 founding members of the society by Jung et al. in 1987. The current survey is to review the present status of the index cases from 1997 to 1999 among 36 members of the KAPS. Two surveys were undertaken for this study. In the first survey, cases were collected by the registration form, composed of neonatal (N), important pediatric surgical cases (I), tumor and other similar operations (T) and other common pediatric surgical cases (O). Thirty members responded, and the result was discussed at the Topic Discussion section of the . 15th annual Congress of KSPA, 2000. The second survey analyzed additive data, proposed during discussion at the Congress. Twenty-three members responded. This report is the analysis of the both surveys. The average numbers of the cases/year/surgeon of N, I, T, O and total were 19.5, 51.6, 9.5, 77.1 and 356.5, respectively. The number of index cases (N+I+T)/year/surgeon was 80.8. The ratio of (N+I+T)/total cases was 0.3. Seventeen of 30 members have more than 20 cases of N per year. Twelve members have more than 150 cases, and 13 do more than 100 cases of I per year. Fourteen members have more than 10 cases of T per year. Nineteen and 10 members experienced more than 150 and 100 of index cases (N+I+T) per year. A new list of the index cases and coding system are proposed for the future regular update.
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[English]
Laparoscopic Meckel's Diverticulectomy in Children
Han, Seok Joo , Kim, Jun Young , Huh, Jeong Wook , Han, Airi , Hwang, Eui Ho
J Korean Assoc Pediatr Surg 2001;7(2):157-161.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.157
Meckel's diverticulum is one of the common causes of gastrointestinal bleeding in the pediatric patient requiring laparotomy. Two children with Meckel's diverticulum have been successfully treated by laparoscopic excision. Both patients recovered without incident and were discharged at 3 and 5 days after surgery. The authors believe that laparoscopic diverticulectomy is a safe, effective, and minimal invasive treatment of Meckel's diverticulum in children.
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Case Reports

[English]
Clear Cell Sarcoma of the Kidney: A case report
Park, Jae Hyun , Jung, Jae Hee , Lee, Ah Won , Song, Young Tack
J Korean Assoc Pediatr Surg 2001;7(2):162-165.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.162
Clear Cell Sarcoma of the Kidney (CCSK) is a rare malignant childhood tumor with frequent metastasis to the bone. We report a case of right sided in a 5 month-old girl. A radical nephrectomy was performed. It was clinical stage III with renal capsular invasion and lymph node metastasis by the classification of NWTS-5. Histologic examination revealed the classic pattern of CCSK. Postoperative adjuvant chemotherapy with doxorubicin and radiotheraphy were applied.
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[English]
A Case of Neonatal Hydrocolpos due to Vaginal Atresia
Jo, Young Jung , Park, Jong Hoon , Kim, Sang Youn
J Korean Assoc Pediatr Surg 2001;7(2):166-169.
DOI: https://doi.org/10.13029/jkaps.2001.7.2.166
A 37-week gestation female neonatal infant presented with lower abdominal distension. Ultrasonography showed a hydrocolpos, measuring 8.3 cm x 6.9 cm x 6.1 cm in size and on perineal examination, vaginal atresia was noticed. On a follow-up ultrasonography performed 41 days after aspiration, the hydrocolpos was enlarged to 10 cm x 8 cm x 7 cm in size, and compressed adjacent small bowel significantly with concomitant bilateral hydronephrosis. Temporary tubed vaginostomy was carried out with the provision of excellent drainage and easy access for contrast studies to outline the pathologic anatomy. We are planning to perform vaginal reconstructive surgery on her age around 2 years, when her vaginal structure might grow sufficiently for reconstructive surgery.
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