Laparoscopic gastric pull-up and thoracoscopic esophago-esophagostomy combined with intrathoracic fundoplication for long-gap pure esophageal atresia.

The management of long-gap pure esophageal atresia (LGEA) remains controversial. An 8-month-old girl with LGEA underwent a laparoscopic and thoracoscopic gastric pull-up and esophago-esophagostomy in the right thorax combined with intrathoracic fundoplication. She was positioned supine, and three 5-mm ports were placed in the standard locations for laparoscopic Nissen fundoplication. The gastrostomy was taken down and an additional 5-mm port was inserted at the gastrostomy site. Laparoscopic gastric mobilization was performed; the short gastric and left gastric vessels were divided using harmonic shears, and the whole stomach and distal esophageal stump maintained their vascular supply via the right gastric and gastroepiploic arteries. The hiatus was enlarged by radial incisions at both cruras, and the mobilized whole stomach and distal esophageal stump were pushed up into the right thorax through the hiatus. The patient was placed in a modified prone position and three 5-mm ports were inserted into the right thorax. Via thoracoscopy, the upper esophageal pouch was dissected bluntly, and an esophago-esophagostomy was performed using interrupted 4-0 absorbable sutures and was wrapped by a 360-degree gastric fundoplication. The patient was positioned supine again, and a Heinecke-Mikulicz pyloroplasty and gastropexy were also performed laparoscopically. The patient has mild respiratory distress that requires bronchodilators; however, she is eating baby food well without vomiting. Postoperative intrathoracic gastrofiberscopy showed a well-functioning antireflux valve, and her parents are also satisfied with the cosmetic appearance of the seven small wounds. Our new procedure is feasible and is an excellent option in selected patients with LGEA.

Cholelithiasis and choledocholithiasis associated with anomalous junction of the cystic duct in a child.

We report an extremely rare case of cholelithiasis, presumably owing to cholestasis resulting from an anomalous course of the cystic duct. A 10-year-old girl visited our hospital because of right epigastric pain and fever. Cholelithiasis and choledocholithiasis were diagnosed by ultrasound examination. Magnetic resonance cholangiopancreatography showed no pancreaticobiliary maljunction but confirmed a dilated, tortuous cystic duct anomalously draining into the right hepatic duct. Because cholangitis and obstructive jaundice progressed after admission, emergent endoscopic retrograde cholangiopancreatography was performed, and a common bile duct stone was removed endoscopically. It was a bilirubin stone. At a later date, laparoscopic cholecystectomy was performed for cholelithiasis. Preoperative 3-dimensional computed tomography and intraoperative cholangiography enabled us to treat the cystic duct safely.

High-grade congenital esophageal stenosis owing to a membranous diaphragm with tracheoesophageal fistula.

Gross E-type congenital esophageal atresia associated with congenital esophageal stenosis is extremely rare. In a male infant born at 36 weeks of gestation, bubbly vomiting was noted after birth. X-ray films of the chest and abdomen showed coil-up sign of the nasogastric tube and gas in the stomach and small intestines were recognized, so gross C-type esophageal atresia was suspected and surgery was performed on the first day of life. Surgery revealed the presence of a tracheoesophageal fistula in the upper esophagus and membranous stenosis on the distal side.

Primary omental-mesenteric myxoid hamartoma of the mesoappendix incidentally detected after abdominal trauma in a child: report of a case.

A 14-year-old boy was brought to our hospital with abdominal pain and nausea after suffering a blow to the abdomen. A mass was felt in the right hypogastrium, and the patient was hospitalized for possible hematoma resulting from the abdominal trauma. Initially, we treated him conservatively and observed his course, but on the 20th day after trauma, enhanced computed tomography showed that the area of strong enhancement in the tumor was unchanged. Superior mesenteric angiography showed findings indicative of a pseudoaneurysm caused by the trauma, and surgery was performed 26 days after the injury. Laparotomy revealed a tumor with a clear boundary, thought to originate in the mesoappendix, without any sign of pseudoaneurysm. Histopathological examination confirmed that the tumor was an omental-mesenteric myxoid hamartoma. The patient had an uneventful postoperative course and was discharged from hospital on the 12th day after surgery. More than 5 years have elapsed since the operation and no sign of recurrence or metastasis has been recognized.

Traumatic rupture of choledochal cyst in a child.

Traumatic rupture of choledochal cyst is an extremely rare disorder. The current patient is a 4-year-old boy who fell in a bathroom and suffered a blow to the abdomen. Percutaneous transhepatic cholangiography revealed pancreaticobiliary maljunction. Inflammation of the peritoneal cavity was moderate. At first look, the choledochal cyst was excised and hepaticojejunostomy was performed. At this time, a rupture approximately 2 mm in diameter was recognized at the rear surface of the inferior part of the common bile duct.