Hiatal hernia is a very rare disease in the pediatric population. However information from our esophageal atresia postoperative follow-up program has hypotheses; “Hiatal hernia may more frequently occur in postoperative esophageal atresia patients (EA group) than in the general pediatric population (GP group)” and “The tension on the esophagus after esophageal anastomosis may be an important etiologic factor of hiatal hernia in EA group”. To prove the first hypotheses, we compared the incidence of hiatal hernia in the GP group with the incidence in the EA group. The Incidence in the GP group was obtained from national statistic data from Statistics Korea and Health Insurance Review and Assessment Service of Korea. The incidence in the EA group was obtained from the medical record and the imaging studies of our esophageal atresia postoperative follow-up program. To prove the second hypothesis, the presumptive risk factors for the development of hiatal hernia in EA group, such as the type of esophageal atresia, degree of esophageal gap, the stage operation and the redo-operation with resection and re-anastomosis of esophagus were analyzed statistically. The total number of patients in the EA group was ninety-nine and there were 5 hiatus hernias. The incidence of EA group (5 %) is significantly higher than incidence of GP group (0.024 %). (p=0.0001) The statistical analysis of the presumptive risk factors for hiatal hernia development in EA group failed to show any evidence of correlation between postoperative esophageal tension and the hiatal hernia. This study shows that the postoperative patients with esophageal atresia have high occurrence of hiatal hernia and should be followed up carefully to detect hiatal hernia.

Although laparoscopic surgery for hepatobiliary disease in children is possible, it is technically challenging. In an attempt to overcome these difficulties, the da Vinci Robotic Surgical System(R) was used to facilitate the minimally invasive treatment of choledochal cyst in six children. In early consecutive three cases, we experienced three complications; a case of laparotomy conversion, a case of late stenosis of the hepaticojejunostomy, and a case of leakage from a hepaticojejunostomy. However, in the last three cases the complete resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy were performed using the robotic surgical system without complication.

We think robot-assisted choledochal cyst resection in children appears safe and feasible, and may increase the variety of complex procedures in pediatric surgical fields.

Meconium obstruction (MO) in neonates arises from highly viscid meconium and the poor motility of the premature gut. Recently the incidence of the MO in neonates has been increasing, but, the diagnosis and treatment of this disease have not yet been clarified. Between March 2004 and April 2010, 24 neonates were treated for MO at Severance Children's Hospital. Their clinical characteristics and treatment were reviewed retrospectively. Twenty neonates were diagnosed with MO and 4 neonates were diagnosed with Hirschsprung's disease (HD). The mean birth weight and gestational age of the 20 neonates with MO were 1.45±0.90kg and 31.1±4.6 weeks, respectively. Thirteen neonates (65%) diagnosed with MO weighed less than 1.5kg and 10 neonates (50%) weighed less than 1kg. Half of the neonates with MO were treated by non-operative methods and the other half were treated by operative methods. Compared with the group that weighed over 1.5kg, the group that weighed less than 1.5kg were more frequently operated upon (61.5% vs. 28.5%), and contrast enemas were performed later and more frequently. Also the group that weighed less than 1.5kg had a higher mortality rate (15.4% vs. 0%). Three of the four neonates with HD were diagnosed with long-segment aganglionosis. In conclusion, MO occurred in very low birth weight neonates more often and must be differentiated from HD. Also, MO in very low birth weight neonates should be treated with special attention due to more a complicated clinical course.

Recently, amniotic fluid has gained attention as one of the potential sources for cell therapy and tissue engineering because it has characteristics of multipotent stem cells. However, current knowledge about what types of cells are naturally found in amniotic fluid is still limited. In this study, we aimed to investigate whether human amniotic fluid contains cells that have characteristics of respiratory cells. Samples of human amniotic fluid (5 mL per sample) obtained from amniocenteses were cultured with small airway growth medium (SAGM). Cells were grown until the third passage and the presence of type II alveolar cells were characterized by inverted microscopy, immunofluorescence, and reverse transcription polymerase chain reaction (RT-PCR). On inverted microscopy, cultured cells showed typical polygonal and cobblestone-like epithelial morphology. The morphology of cells was not changed after selection and passing. Immunofluorescence analysis demonstrated that the isolated cells stained positive for surfactant protein C (SPC), specific marker for type II alveolar cells. Cells also stained positive for TTF-1 protein but negative for CD 31 and vimentin. RT-PCR analysis of cells showed expression of SPC mRNA. This study has demonstrated that respiratory cells can be isolated and identified from human amniotic fluid cultured in SAGM medium. Our results may provide the basis for further investigations of amniotic fluid.

Foreign body ingestion is a frequent event in the pediatric age group, but the incidence of foreign bodies in the appendix is very low. The authors report a case of ingested foreign body trapped in the appendix in a 7-year-old girl. The foreign body was successfully treated by laparoscopic appendectomy under fluoroscopic guidance.

The authors applied anterior sagittal transrectal apporach (ASTRA) for the repair of urethrovaginal fistula which developed after total repair of persistent cloaca. The patient had been diagnosed to have persistent cloaca, double uterus and double vagina, and received PSARP, excision of right-side uterus and vagina, and left vaginal switch operation at 22 months old. After operation, the patient admitted several times due to frequent urinary tract infection and ectopic stone formation in bladder and neovagina. Urethro-neovaginal fistula was confirmed by cystoscopy and corrected with ASTRA. Postoperative voiding cystourethrogram showed no fistula tract. ASTRA showed improved surgical field, minimized ureterocystic damage, and preserved perirectal nerve due to limited incision of rectum.

The use of subcutaneously tunneled, cuffed central venous catheters like Broviac's or Hickman's has increased and complications related to catheter removal has also increased. However, there are only few reports of complications that occur at the time of removal. The authors report an unusual case of catheter fracture during removal of Broviac catheter.

Appendicitis is the most common surgical emergency in childhood and the technologic advances of modern medicine have affected the diagnosis and treatment of appendicitis. This study is to evaluate the differences in diagnosis and treatment of appendicitis between present and 10 year ago. The authors retrospectively reviewed the medical records of patients who underwent appendectomy under the diagnosis of the acute appendicitis from July 1993 to June 1995 (Group A, n = 78) and from July 200 to June 2005 (Group B, n = 105). There are no differences between group A and B in mean age (8.5 ±3.6 vs. 9.3 ±3.1 year), duration of symptoms (3.0 ±3.2 vs. 2.6 ±3.8 days), and postoperative hospital stay(6.6 ±4.8 vs. 5.8 ±3.6 days). Preoperative abdominal ultrasonogram and/or computed tomogram was performed in 7 patients (9.0 %) of group A and in 51 patients (58.5 %) of group B. Thirty-six patients (34.3 %) of group B underwent laparoscopic appendectomy, but none in group A. Incidence of a histologically normal appendix decreased from 15.8 % in group A to 4.8 % in group B (p =0.018). This study suggests that utilization of abdominal ultrasonogram or computed tomogram in preoperative evaluation become more popular and surgical treatment of acute appendicitis become more minimally invasive. The rate of negative appendectomy was also reduced compared with 10 year ago.

This case report describes a baby who received a laparoscopic gastrostomy tube insertion, which was dislodged accidentally at 16(th) postoperative day. After the dislodgement, cutaneous tract rapidly closed, and reinsertion seemed to be impossible. However, gastrostomy tube was reinserted safely with fluoroscopy-guided Seldinger's technique under local anesthesia with sedation. This is the unique method of modified Seldinger's technique for reinsertion of gastrostomy tube under local anesthesia and sedation for accidentally dislodged gastrostomy tube. This method was thought to be safe, easy and useful technique for gastrostomy reinsertion after dislodgement of gastrostomy tube.

Solid pseudopapillary tumor (SPT) of the pancreas occurs most frequently in the second or third decades of life, and is prevalent in females. Unlike other pancreatic malignancy, SPT usually has a low malignancy potential. This study reviews our clinical experience and surgical treatment of pancreatic SPT. Admission records and follow-up data were analyzed retrospectively for the period between January 1996 and January 2003. Five patients with a pancreatic mass were operated upon and SPT was confirmed by pathology in each case. The male to female ratio was 1 : 4. The median age was 13.8 years. Findings were vague upper abdominal pain (n=5, 100 %) and an abdominal palpable mass (n=3, 60 %). The median tumor diameter was 6.8cm and the locations were 2 in the pancreatic head (40 %) and 3 in the pancreatic tail (60 %). Extra-pancreatic invasion or distant metastasis was not found at the initial operation in all five cases. A pyloruspreserving pancreaticoduodenectomy (n=1) and a mass enucleation (n=1) were performed in two patients of pancreatic head tumors. For three cases of tumors in pancreatic tail, distal pancreatectomy (n=2) and combined distal pancreatectomy and splenectomy (n=1) were performed. The median follow-up period was 60 months(12-117month). During the follow-up period, there was no local recurrence, nor distant metastasis. Postoperative adjuvant chemotherapy or radiotherapy was not carried out. All five children were alive during the follow up period without any evidence of disease relapse. SPT of the pancreas in childhood has good prognosis and surgical resection of the tumor is usually curative.

The prognostic factors for extrahepatic biliary atresia (EHBA) after Kasai portoenterostomy include the patient's age at portoenterostomy (age), size of bile duct in theporta hepatis (size), clearance of jaundice after operation (clearance) and the surgeon's experience. The aim of this study is to examine the most significant prognostic factor of EHBA after Kasai portoenterostomy. This retrospective study was done in 51 cases of EHBA that received Kasai portoenterostomy by one pediatric surgeon. For the statistical analysis, Kaplan-Meier method, Logrank test and Cox regression test were used. A p value of less than 0.05 was considered to be significant. Fifteen patients were regarded as dead in this study, including nine cases of liver transplantation. There was no significant difference of survival to age. The age is also not a significant risk factor for survival in this study (Cox Regression test; p = 0.63). There was no significant difference in survival in relation to the size of bile duct. However, bile duct size was a significant risk factor for survival (Cox Regression test; p = 0.002). There was a significant difference in relation to survival and clearance (Kaplan-Meier method; p = 0.02). The clearing was also a significant risk factor for survival (Cox Regression test; p = 0.001). The clearance of jaundice is the most significant prognostic factor of EHBA after Kasai portoenterostomy.

Inguinal hernia is the most common disease treated by the pediatric surgeon. There are several controversial aspects of management 1)the optimal timing of surgical repair, especially for preterm babies, 2)contralateral groin exploration during repair of a clinically unilateral hernia, 3)use of laparoscope in contralateral groin exploration, 4)timing of surgical repair of cord hydrocele, 5)perioperative pain control, 6)perioperative management of anemia. In this survey, we attempted to determine the approach of members of KAPS to these aspects of hernia treatment. A questionnaire by e-mail or FAX was sent to all members. The content of the questionnaire were adapted from the “American Academy of Pediatrics (AAP) Section on Surgery hernia survey revisited (J Pediatr Surg 40, 1009-1014, 2005)”. For full-term male baby, most surgeons (85.7 %) perform an elective operation as soon as diagnosis was made. For reducible hernia found in ex-preterm infants already discharged from the neonatal intensive care unit (NICU), 76.2 % of surgeons performed an elective repair under general anesthesia (85.8 %). 42.9 % of the surgeons performed the repair just before discharge. For same-day surgery for the ex-premature baby, the opinion was evenly divided. For an inguinal hernia with a contralateral undescended testis in a preterm baby, 61.9 % of surgeons choose to ‘wait and see’ until 12 month of age. The most important consideration in deciding the timing of surgery of inguinal hernia in preterm baby was the existence of bronchopulmonary dysplasia (82.4 %), episode of apnea/bradycardia on home monitoring (70.6 %). Most surgeons do not explore the contralateral groin during unilateral hernia repair. Laparoscope has not been tried. Most surgeons do not give perioperative analgesics or blood transfusion.

Esophageal atresia without tracheoesophageal fistula accounts for 7-11% of all types of esophageal atresia and is very difficult to treat. In our hospital from 1990 to 2005, we operated upon 40 patients with esophageal atresia, and 6 had pure atresia. The preoperative characteristics, operative findings and post operative course of the six patients with pure atresia were analysed. Immediate gastrostomy was performed in all 6 patients. One patient had simultaneous cervical esophagostomy. Esophageal reconstruction procedures were transhiatal gastric pull up in 3 patients, esophagocologastrostomy utilizing left colon in 1, and transthoracic esophagoseophagostomy with esophageal bougination in 2. Postoperative complications were pneumonia, anastomosis leakage, and gastroesophageal reflux symptom. Conservative management was effective in all patients. A larger series of cases would be required to demonstrate the most effective treatment for this particular anomalous condition.

Recently, the incidence of perinatally detected asymptomatic adrenal gland masses has increased because of widespread use of radiological diagnostic tools. However, optimal treatment of these masses has not been determined. The aim of this study is to elucidate the treatment guideline of perinatally diagnosed adrenal gland masses. The authors retrospectively reviewed the medical records of the 11 patients with asymptomatic adrenal gland mass, detected perinatally, between 1999 and 2004. Six cases were detected by prenatal ultrasound and 5 cases were incidentally detected by postnatal ultrasound. Six patients (surgery group) underwent mass excision. The pathologic diagnoses were neuroblastoma (n=4), adrenocortical adenoma (n=1) and adrenal pseudocyst (n=1). The indications for operation were suspicion of neuroblastoma (n=5) or absence of size decrease during observation (n=1). Three of the 5 suspicious cases of neuroblastoma and one case under observation were proven to be neuroblastoma. There was no surgical complication in the urgery group. All neuroblastoma patients have been well during the follow up period (24.4±14.4 month) without evidence of recurrence. Five cases (observation group) were closely observed because of the benign possibility or size decrease in follow up ultrasound. During the observation period (39±21 week), 4 cases showed complete spontaneous resolution and 1 case showed markedly decreased size of the mass but could not be followed up completely. Surgical resection of the perinatally diagnosed asymptomatic adrenal gland mass is a safe treatment method especially in case of suspicion of neuroblastoma, but closed observation can be applied.

It has been widely accepted that complete surgical resection of hepatoblastoma is essential for long-term survival. But unfortunately less that 50% of hepatic tumors in children can be totally removed at the time of diagnosis. This report is to present the experience of successful resection of hepatoblastoma after concurrent radiotherapy with transarterial chemoinfusion in a child. We believe this modality of treatment enables complete resection of unresectable hepatoblastoma, which is resistant to the systemic chemotherapy.

In hepatoblastoma, encouraging cure rates have been achieved with recent advances in chemotherapy and surgical techniques. The aim of this study is to evaluate the role of combined therapeutic modalities and surgical resection in hepatoblastoma. Fifteen cases of hepatoblastoma were treated from January 1993 to August 2000. Six patients had resectable tumors at initial diagnosis. All underwent surgical resection and in four patients postoperative adjuvant chemotherapy was needed. Nine out of 15 patients had unresectbale tumors at initial diagnosis, and preoperative chemotherapy was applied. There was one operative mortality and 14 patients showed good prognosis after surgery. Although various treatment modalities should be combined for the unresectable hepatoblastoma, surgical resection remains the major curative procedure.

Neuroblastoma arises from the embryonic tissue of the adrenergic rest. It is commonly found in children and mostly in nonrenal tissue. We present a case of intrarenal neuroblastoma which was initially thought to be a Wilms' tumor. The patient was a 18 months-old girl treated with radical nephrectomy and adjuvant chemotherapy after operation. The neoplasm within the kidney in children cannot always indicate Wilms' tumor. Neuroblastoma of the adrenal gland or retroperitoneal tissue may often compress or invade the kidney directly or arise from the kidney. Clinical aspects that differentiate between neuroblastoma and Wilms' tumor are discussed with a review of the literatures.

Pseudoaneurysm of splenic artery may arise from a vascular erosion by the inflammatory processes around the splenic artery, particularly in acute pancreatitis and chronic pancreatitis, which may cause rupture of pseudoaneurysm and life threatening hemorrhage. Collective experience with this massive hemorrhage is attended by a high mortality rate even with prompt therapy, and conservative management is associated with an almost 100 per cent of mortality rate. Identification of the bleeding site at laparotomy may be exceedingly difficult, which makes the preoperative detection of bleeding source desirable. Peripancreatic vascular lesions can be identified by angiography, and in selected cases the risk of urgent operation to control massive hemorrhage may be obviated by embolization. The authors have recently experienced a case of ruptured splenic artery pseudoaneurysm combined with a pancreatic pseudocyst in a 6 years old boy. A bolus enhanced CT scan and angiography were essential to confirm these complications of pancreatic pseudocyst. We managed this child successfully with an urgent procedure of transcatheter arterial embolization and another elective surgery of pancreatic pseudocyst.

Femoral hernias are very uncommon in children and very easily misdiagnosed. During a period of three years, three children of femoral hernia were treated by one pediatric surgeon at Severance Hospital. Only one case was diagnosed correctly before surgery; the other two were thought to be either an indirect inguinal hernia or groin mass. Only one patient had curative hernioplasty (McVay hernioplasty) at the first operation; the other two did not have curative hernioplasty at the first operation. Femoral hernia in childhood is a challenging clinical problem because of its rarity and similar clinical presentation as indirect inguinal hernia. The frequency with which an incidental indirect inguinal hernia sac or patent processus vaginalis can be found at surgery can perpetuate a misdiagnosis. The absence of an expected indirect inguinal hernia sac or an apparent recurrence of an indirect inguinal hernia should lead to consideration of possible femoral hernia.

Evaluation of the sacrum in anorectal malformations (ARMs) is important because of the frequent association with ARMs and functional outcome after correction of ARMs. Sacral defects are not easily detected because of immaturity of sacrum in children and overlooking of pediatric surgeons. The authors utilized the sacral ratio in normal children and patients with ARMs. In normal children, the mean true sacral ratio and mean sacrococcygeal ratio were 0.60±0.08 and 0.72±0.13 respectively. Sacral ratio was not correlated with age and did not changed with age in same patient. However, true sacral ratio and sacrococcygeal ratio were significantly lower in patients with high type ARMs than those of normal children (p<0.001). There was no difference between patients with low type ARMs and normal children. These results suggest that abnormal sacrums are more frequently encountered in patients with high type ARMs than in normal children, and that true sacral ratio and sacrococcygeal ratio can be used in the evaluation of the abnormal sacrum.

The surgical treatment of intussusception during two periods, 1975 - 1978 and 1995 -1998 (Group B) were compared. There were 48 patients in Group A and 75 cases in Group B. Male were predominant in both group (2.7:1 vs 1.6:1). The mean age at operation was 6.7 ± 5.0 months (Group A) and 8.1 ± 7.0 months (Group B). The major signs and symptoms in both Groups included vomiting, hematochezia and irritability. There was a significantly higher bowel resection rate for group B (31.3 % vs 14.7 %, p=0.041 ). There were two operative deaths in group B but no deaths in group A. Hospitalization was significantly shorter in group B(7.5 ± 2.7 days vs 5.4 ± 2.1 days, p<0.001). We conclude that there were no differences in patient characteristics but surgical treatment in the 1990s results in more rapid recovery and reduced hospital stay.

We have treated a case of pseudocyst of transverse mesocolon in 3-year-old male child. Operative findings demonstrated that the pseudocyst originated in the transverse mesocolon, and was not connected to the pancreas. A colonic duplication was found incidentally near the pseudocyst. On microscopic examination, ectopic pancreatic tissue was noted in the transverse mesocolon. This pseudocyst was thought to have originated from the ectopic pancreas of the transverse mesocolon. This is the first reported case of pseudocyst originated from ectopic pancreas of the transverse mesocolon, combined with a colonic duplication. The pathogenesis is discussed.

Three cases of laparoscopic splenectomy for hereditary spherocytosis are reported. The average operation time was 100 minutes. This was longer than traditional open splenectomy for the same entity( 63 minutes). Average hospitalization period was 3 days. This was shorter than the hospitalization period for the traditional group(6.2 days).

Transhiatal gastric transpositions were performed in two case of long gap esophageal atresia without tracheoesophageal fistula. The patients were a 12 months old female and an 18 months old male. Stamm type gastrostomies were performed at other hospitals in both cases. The stomach was mobilized preserving the right gastric artery, the right gastroepiploic artery and spleen. The proximal and distal esophageal pouches were excised by transcervical and transhiatal route, respectively. The mobilized stomach was pulled up to the neck through esophageal hiatus and posterior mediastinal route. The esophagogastrostomy, the only one anastomosis of this procedure, was performed in the neck. There was no clinical evidence of anastomotic leakage, stricture, regurgitation, difficulty of gastric emptying, hoarseness or respiratory problem. Transhiatal gastric transposition seems to be a safe and easy alternative surgical procedure for esophageal replacement in long gap esophageal atresia.

Bacillus Calmette-Guerin(BCG) lymphadenitis is a complication of post-BCG vaccination and its treatment is still controversial. Eighty patients who had been operated for BCG lymphadenitis from 1987 to 1996 were reviewed. Thirty-one of them were treated with antituberculous drugs(mean dunition: 3 months) preoperatively and 49 patients were not given preoperative antituberculous medication. No one was treated with antituberculous drugs postoperatively. Operation methods were excision(72) and partial excision with curettage(8). There was no statistical difference in recurrence rate between groups In two patients(2.5 %) treated with preoperative antituberculous drugs, the lesions recurred after operation. The results suggest that preoperative antituberculous medication does not play any role in the treatment of BCG lymphadenitis and in preventing recurrence in surgically excised cases.