The learning curve of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia: protocoled training in a single center for six pediatric surgical trainees.

BACKGROUND: Laparoscopic percutaneous extraperitoneal closure (LPEC) has become a common procedure for repairing inguinal hernia. As a laparoscopic approach, pediatric surgical trainees require more training to learn LPEC than a traditional open approach. This study aimed to clarify the experience needed to acquire the skill to perform LPEC adequately. METHODS: This descriptive single-center study used clinical data from patients who underwent LPEC between May 2009 and May 2016. The mean operative time for ten consecutive unilateral repairs was used as an index of proficiency with the procedure. The number of repairs performed before the mean operative time became less than 20 min was evaluated for each trainee. RESULTS: During the study period, six pediatric surgical trainees participated in the training independently. The number of the patients was 987. The total number of repairs was 1436, including 538 unilateral repairs and 449 concurrent bilateral repairs. Overall, the mean operative time was 21.8 ± 8.1 min for unilateral repair and 31.4 ± 9.7 min for concurrent bilateral repairs. The mean number of repairs performed before the acquisition of skill for dexterous LPEC was 125.1 ± 29.5. CONCLUSIONS: Although there were individual differences, all trainees acquired the skill to perform LPEC adequately within one year. With appropriate guidance, LPEC can become a standard technique for pediatric surgical trainees, along with traditional open surgery. These results provide valuable information for planning LPEC training.

Liver transplantation for deterioration in native liver function after portoenterostomy for biliary atresia in Japan: Short- versus long-term survivors.

PURPOSE: We reviewed our post-Kasai portoenterostomy biliary atresia (BA) patients who required liver transplantation (LTx) for deterioration in native liver (NL) function to investigate mortality in relation to age at LTx. METHODS: BA patients indicated for LTx when less than 18years old (U18; n=17) and when 18 or older (18+; n=13) were compared. All achieved jaundice clearance postoperatively (TBil ≤1.2mg/dL (≈20µmol/L)). RESULTS: In U18, living-donor (LD) LTxs were performed at a median of 6.1years (range: 0.5-16.7; n=14) and cadaveric (CD) LTxs at a median of 1.3years (1.1-1.5; n=3). In 18+, LDLTxs were performed at a median of 28years (18-37; n=8), and 1 case died from graft versus host disease. CDLTxs were indicated in 5, but 4 died at a median of 30years (26-32), a mean of 1.4years (0.7-1.8) after NL deterioration commenced. One case is awaiting CDLTx. At the time of review, all U18 and 7 LDLTx cases in 18+ were clinically stable. Mortality rates were 0% in U18 and 38% in 18+ (P=.006). CONCLUSION: Our results highlight the extremely grave prognosis for long-term BA patients requiring LTx when 18 or older because of poor donor availability in Japan. LEVEL OF EVIDENCE: Level III.

Bowel obstruction without history of laparotomy: Clinical analysis of 70 patients.

BACKGROUND: Determining the cause of bowel obstruction without a history of laparotomy (BO without HL) is difficult and can result in delay of treatment and development of a potentially life-threatening situation. We herein investigated the clinical characteristics of pediatric patients who underwent laparotomy due to BO without HL. METHODS: All surgical pediatric patients aged <16 age who were diagnosed with BO without HL between January 2004 and September 2014 were included. Etiology of BO, intraoperative findings and postoperative outcome were investigated retrospectively. RESULTS: Seventy patients were diagnosed with BO without HL in this period. In these 70 patients, malrotation (n = 34), intussusception (n = 19), internal hernia (n = 6) and Meckel's diverticulum (n = 5) were predominantly identified. Regarding preoperative definitive diagnosis, prevalence of internal hernia, Meckel's diverticulum or idiopathic volvulus was significantly lower than that of malrotation or intussusception (P < 0.05). Intraoperatively, the rates of strangulation and bowel resection were 55.7% and 30.0%, respectively. The optimal time for emergency operation in order to avoid strangulated bowel resection was <19 h from onset of symptoms. CONCLUSIONS: Malrotation and intussusception are major causes of BO without HL in children, but internal hernia, Meckel's diverticulum and idiopathic volvulus should always be taken into account, particularly because of the preoperative diagnostic difficulty and resulting high rate of intestinal resection. In order to avoid resection of the bowel, surgery should be done within 19 h before bowel ischemic change occurs.

Experience of treating biliary atresia with three types of portoenterostomy at a single institution: extended, modified Kasai, and laparoscopic modified Kasai.

PURPOSE: Generally, open portoenterostomy (PE) involves a wide extended anastomosis and all sutures are deep [extended PE (EP)]. In contrast, the anastomosis in Kasai's PE (KP), our modified open Kasai PE (MK), and our laparoscopic modified Kasai PE (lapMK) involve shallow suturing, especially at the 2 and 10 o'clock positions where the right and left bile ducts would be normally. We compared outcomes of 36 consecutive biliary atresia (BA) patients treated by three types of PE at a single institution during the period 2005-2014; EP (n = 13), MK (n = 11), and lapMK (n = 12). METHODS: We compared age at PE, time taken to become jaundice-free (total bilirubin ≤1.2 mg/dL; JF time), proportion of JF subjects [JF ratio (JFR)], steroid dosage, incidence of cholangitis, postoperative liver function and CRP, presence of hypersplenism, requirement for liver transplantation (LTx), and JF survival with the native liver (JF+NL) as indicators of outcome. RESULTS: Patient demographics, steroid dosage, JF time, incidence of cholangitis, presence of hypersplenism, operating time, blood loss and postoperative biochemistry were similar for all groups. However, JFR was significantly higher for lapMK (100 %) versus EP (46.2 %) (p < 0.05), but not for MK (81.8%) versus EP. Kaplan-Meier analysis showed survival with NL was significantly higher for lapMK (10/12: 83.3%: JF in 9; not JF in 1) and MK (9/11: 81.8 %: JF in all) versus EP (3/13: 23.1%: JF in all) (p < 0.05, respectively), but not for lapMK versus MK. JF+NL in both lapMK (9/12: 75.0%) and MK (9/11: 81.8%) were significantly higher compared with EP (3/13: 23.1%) (p < 0.05, respectively). Intraperitoneal adhesions were less pronounced at LTx in lapMK compared with MK or EP. CONCLUSIONS: This study would suggest that depth of suturing during PE would appear to influence post-PE outcome. LapMK should be reconsidered as a valid treatment option for BA.

Factors influencing jaundice-free survival with the native liver in post-portoenterostomy biliary atresia patients: results from a single institution.

PURPOSE: We reviewed post-portoenterostomy (PE) biliary atresia (BA) patients who became "jaundice-free" (JF; total bilirubin (T-bil) ≤1.2 mg/dL) to determine factors associated with survival with the native liver (SNL). METHODS: We reviewed 76 BA patients treated by PE at our institute between 1989, when liver transplantation (LTx) became available in Japan, and 2012, prospectively. Of these, 60 who became JF and remained JF were divided into two groups, SNL (n=44) and LTx (n=16). Age and weight at PE, pre- and post-PE T-bil, AST, γ-GT, time taken to become JF, corticosteroid requirements, incidence of cholangitis, and micro-bile duct size were compared between the two groups. RESULTS: The SNL patients became JF significantly earlier: 58 vs. 115 days (p<.05). Corticosteroid requirement, cholangitis, and postoperative AST/γ-GT were significantly lower in the SNL patients (p<.05). SNL was significantly higher if patients became JF ≤60 days post-PE (p<.01). LTx was performed from 0.5 to 11 years post-PE (mean=3.4). All patients who had cholangitis within 3 months of PE eventually required LTx (p<.05). CONCLUSIONS: Becoming JF ≤60 days post-PE would appear to be a factor associated with SNL, while cholangitis within 3 months of PE would appear to be associated with LTx. Elevation of AST and γ-GT would also appear to be early indicators of risk for LTx during follow-up of JF patients after successful PE.

Reappraising the portoenterostomy procedure according to sound physiologic/anatomic principles enhances postoperative jaundice clearance in biliary atresia.

BACKGROUND: The portoenterostomy (PE) procedure for treating biliary atresia (BA) has been so repeatedly modified that it currently hardly resembles Kasai's original PE (KOPE). Now PE involves an extended lateral dissection and a wide anastomosis (extended PE: EPE). We reappraised KOPE and created our-KOPE (OKOPE) by adhering strictly to its principles and techniques. We compared outcome of EPE and OKOPE. METHODS: We reviewed 24 consecutive cases of PE for BA performed at our institution from 2005 to 2011. Thirteen had EPE, and 11 had OKOPE. Body weight, serum total bilirubin, age at PE, total steroid dosage required for jaundice clearance (JC: total bilirubin ≤1.2 mg/dL), JC ratio, time taken for JC, survival rate with the native liver (SNL), and SNL after JC (SNL + JC) were compared at 16 months (shortest mean follow-up). Postoperative management protocols were identical for both groups. RESULTS: The JC ratio was significantly higher for OKOPE (90.9%) than EPE (46.2%) (p = 0.02). Both SNL and SNL + JC were significantly higher for OKOPE (90.9 and 72.7%) than EPE (30.8 and 30.8%) (p = 0.003 and p = 0.04, respectively). All other variables were similar for both groups. CONCLUSIONS: Jaundice clearance following OKOPE would appear to be better than after EPE.