Effectiveness of Interval Appendectomy After Conservative Treatment of Pediatric Ruptured Appendicitis with Abscess.

The management of patients with acute perforated appendicitis with abscess is controversial. The aim of the present study was to assess the outcomes of treatment in patients with this condition. We retrospectively analyzed 31 patients (16 men and 15 women with a mean age of 8.4 years) with appendicitis presenting with abscess. Patients were divided into two groups (emergency operation group and interval operation group), and clinical characteristics and outcomes of treatment were investigated. On presentation, no differences in gender, age, body weight, duration of symptoms, temperature, white blood cell count, C-reactive protein level, or maximum size of the abscess in the axial view were detected between the two groups. Fifteen patients (48.4 %) underwent emergency surgery. The remaining 16 patients (51.6 %) were initially treated conservatively with antibiotics. All 16 patients underwent planned operations after receiving conservative treatment, and two (12.5 %) of these patients underwent appendectomy before the planned operation day because of recurrent appendicitis without abscess. There were no differences in the length of hospital stay. In the emergency operation group, six (40 %) patients presented with wound infection and four (26.7 %) developed a postoperative intra-abdominal abscess. No infective complications were reported in the interval operation group. Interval appendectomy after conservative treatment of pediatric ruptured appendicitis with abscess significantly reduced postoperative infection rates.

Evaluation of the efficacy of incision and drainage versus hainosankyuto treatment for perianal abscess in infants: a multicenter study.

PURPOSE: We retrospectively compared the short-term outcomes between incision and drainage (ID) and hainosankyuto (TJ-122, Tsumura & Co, Tokyo, Japan) treatment for perianal abscess (PA) in infants. METHODS: We retrospectively examined 48 consecutive patients (median age 129 days; range 19-330 days) who presented with PA over a 3 year period. Group 1 comprised 26 patients who were treated with ID at presentation, and Group 2 comprised 22 patients who were treated with oral TJ-122 at presentation; oral treatment was continued until the disappearance of purulent discharge and resolution of induration at the abscess site. RESULTS: PAs were identified in all 48 patients at presentation. The median duration of follow-up was 26 months (range 13-40 months). At presentation, there were no differences in the gender, age, birth weight, duration of symptoms, skin erosion or prevalence of diarrhea between the two groups. Purulent discharge resolved within a median period of 26 days (range 7-42 days) in Group 2, but persisted for 40 days (range 4-196 days) in Group 1. The induration resolved within a median period of 39 days (range 7-91 days) in Group 2, but persisted for 70 days (range 4-308 days) in Group 1 (p = 0.04). CONCLUSIONS: TJ-122 treatment was more beneficial than ID in treating PA in infants.

Long-term results of seton placement for fistula-in-ano in infants.

BACKGROUND: The present study aimed to assess the long-term results of seton placement for fistula-in-ano (FIA) in infants. METHODS: Data of patients aged <1 year who presented to our department with perianal abscess (PA) between January 2006 and February 2010 were retrospectively reviewed. Our standard initial treatment for PA was incision and drainage. Patients with systemic diseases and inflammatory bowel diseases were excluded. RESULTS: Ninety-five patients were treated for PA and/or FIA during the 5-year period, and follow-up data were available for 90 patients. The mean follow-up duration in these patients was 49.8 ± 11.4 months, and mean age at presentation was 3.1 ± 2.7 months. Of the 90 patients, 36 (40%) developed FIA (39 lesions) and underwent seton placement. The condition healed in a mean period of 6.3 ± 4.0 weeks after the placement of a cutting seton. Healing of the fistula was achieved in 35 (97.2%) of 36 patients after the initial seton procedure, and one patient who showed recurrence underwent a second seton placement, resulting in successful healing of the FIA after 5 weeks. CONCLUSIONS: The long-term success of seton placement indicates that this procedure should be a treatment option for FIA in infants.

[Malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis].

PURPOSE: To investigate the clinical findings of patients who underwent surgery for small bowel obstruction following a previous operation for colorectal cancer. We assessed consecutive patients operated on for peritoneal metastasis with small bowel ileus. PATIENTS AND METHODS: We evaluated the clinical characteristics of 7 consecutive patients with malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis. RESULTS: 1) Primary cancer location: descending colon, 2 cases (28.6%); sigmoid colon, 1 case (14.3%); and rectum, 4 cases (57.1%). 2) Peritoneal dissemination grade: P2, 1 case (14.3%); and P3, 6 cases (85.7%). 3) Liver metastasis grade: H1, 1 case (14.3%); H2, 5 cases (71.4%); and H3, 1 case (14.3%). 4) Lymph node metastasis grade: N2, 1 case (14.3%); and N3, 6 cases (85.7%). 5) Extra-abdominal metastasis: multiple lung metastases were detected in 3 cases (42.9%). 6) Pathological type: moderately differentiated tubular adenocarcinoma (tub2), 3 cases (42.3%); poorly differentiated adenocarcinoma (por), 1 case (14.3%); and mucinous adenocarcinoma (muc), 3 cases (42.3%). The differentiated type (tub2) was more common than the undifferentiated types(por and muc). 7) Malignant small bowel stenosis and/or obstruction: there were 3 or more cases with stenosis and/or obstruction in jejunum and ileum. 8) OPERATIVE PROCEDURE: gastrostomy was performed in 2 cases (28.6%); nephrostomy was performed in 1 case (14.3%); gastrostomy with nephrostomy was performed in 1 case (14.3%); and probe laparotomy was performed in 3 cases (42.9%). 9) Survival time of patients with recurrent colorectal cancer, from readmission to death: 0.5-1 month, 3 cases (42.9%); 1-1.5 months, 3 cases (42.9%); and 1.5-3 months, 1 case (14.3%). All patients died in less than 3 months. CONCLUSIONS: The prognosis of the malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis is very bad.

Long-term follow-up of nutritional status, pancreatic function, and morphological changes of the pancreatic remnant after pancreatic tumor resection in children.

OBJECTIVES: The objectives of the present study were to determine nutritional status, pancreatic function, and morphological changes of the pancreatic remnant after pancreatic tumor resection in children. METHODS: The nutritional status was evaluated by the patterns of growth. Pancreatic function was evaluated by using a questionnaire, the Bristol stool form chart, the serum levels of fasting blood glucose, and hemoglobin A1c (HbA1c). Morphological changes of the pancreatic remnant were evaluated by computed tomography, magnetic resonance image, or magnetic resonance cholangiopancreatography. RESULTS: The present study consisted of 6 patients with pancreatic tumor (5 solid pseudopapillary tumors of the pancreas and 1 pancreatoblastoma) who underwent the following operations: tumor enucleation (3), distal pancreatectomy with splenectomy (1), and pylorus-preserving pancreatoduodenectomy (PPPD [2]). The serum levels of HbA1c have been gradually elevated in 2 patients with PPPD. A significant decrease in pancreatic parenchymal thickness and dilatation of the main pancreatic duct were observed in 2 patients with PPPD. CONCLUSION: Endocrine pancreatic insufficiency after PPPD may be explainable by obstructive pancreatitis after operation. Taking together the results of pancreatic endocrine function and morphological changes of pancreatic remnant after PPPD, tumor enucleation should be considered as surgical approach in children with pancreas head tumor whenever possible.

Application of high-dose rate (60)Co remote after-loading system for local recurrent neuroblastoma.

The local control of neuroblastoma is a very important treatment consideration. We describe a patient who received high-dose rate 60Co remote after loading system treatment for local control of recurrent neuroblastoma and discuss the efficacy of high-dose rate 60Co remote after loading system treatment.

The clinical course in pediatric solid tumor patients with focal nodular hyperplasia of the liver.

BACKGROUND: Focal nodular hyperplasia (FNH) of the liver is a rare benign lesion that may be related to the vascular and hepatic damage induced by completion of tumor therapy and a reaction to localized vascular abnormality. The aim of this study was to analyze the clinical course in pediatric solid tumor patients with FNH. METHODS: We analyzed thirty-two patients with pediatric solid tumors who received multiagent chemotherapy (15 advanced neuroblastomas, 7 hepatoblastomas, 5 rhabdomyosarcomas, 2 nephroblastomas, 1 rhabdoid tumor of the kidney, 1 clear cell sarcoma of the kidney and 1 pancreatoblastoma). All of them had been previously treated at our hospital, and have been alive for over 3 years without recurrence. RESULTS: FNH lesions were discovered in three (9.4%) of 32 patients, and were neuroblastoma (NB) stage 4. All 3 patients received induction chemotherapy and high-dose alkylating agents, and developed grade 3 (National Cancer Institute Common Toxicity Criteria; NCI-CTC) liver dysfunction during completion of tumor therapy without veno-occlusive disease. Two of the 3 patients received the same induction chemotherapy and high doses of alkylating agents with total body irradiation for cytoreductive agents prior to peripheral blood cell transplantation. FNH lesions in both female patients who received estrogen replacement therapy after completion of tumor therapy have expanded and are increasing. CONCLUSION: FNH appears to be a late complication of iatrogenic disease in NB stage 4 patients. The therapeutic agents for NB stage 4 and estrogen replacement therapy should be considered as risk factors for the development of FNH.

Therapeutic strategies of meconium obstruction of the small bowel in very-low-birthweight neonates.

BACKGROUND: Meconium obstruction without cystic fibrosis in low-birthweight neonates is a distinct clinical entity. We aimed to determine what therapeutic strategies work best in very-low-birthweight neonates with meconium obstruction of the small bowel under varied clinical conditions caused by the associated diseases of prematurity. METHODS: Medical records of very-low-birthweight neonates with meconium obstruction of the small bowel treated from 1998 to 2008 were retrospectively reviewed. Pre- and postnatal data, treatments, and clinical outcomes were assessed. RESULTS: Nine patients with perinatal complications were identified. Mean gestational age and birthweight were 26.9 weeks and 863 g, respectively. Abdominal distension developed from 1 to 7 days of life. Five patients were initially treated with Gastrografin enema, three of whom had successful outcomes. Two hemodynamically unstable patients failed to respond to Gastrografin treatment; they ultimately died of sepsis. The remaining four without Gastrografin treatment underwent enterostomy to resolve the obstructions with good results. CONCLUSIONS: Gastrografin and surgical treatments should be appropriately selected based on the underlying pathologies of meconium obstruction of the small bowel. Therapeutic Gastrografin enema is effective, safe and repeatable; however, it is not recommended for hemodynamically unstable patients. Surgical intervention is reserved for those who develop rapid abdominal distension that risks perforation.

Persistent biliary dilatation and stenosis in postoperative congenital choledochal cyst.

BACKGROUND/PURPOSE: Cholangitis and intrahepatic stones occur long after total cyst excision in patients with congenital choledochal cyst (CCC). Our study aimed to characterize morphological features of intrahepatic biliary dilatation and stenosis before and after total cyst excision, based on long-term follow-up data. METHODS: Pre- and postoperative morphological features of intrahepatic biliary dilatation were determined in 63 patients with CCC. RESULTS: Postoperatively, hepatic ductal dilatation persisted in 50 patients and hepatic ductal dilatation with stenosis in 35 patients. Hepatic duct stenosis was seen in 35 patients: unilateral hepatic duct stenosis in 21, and bilateral stenosis in 14. Stenosis at the confluence of the right and left hepatic ducts occurred more often in the cystic type of dilatation than in the cylindrical type and was seen more often on the left side than the right. Cases with postoperative cholangitis or intrahepatic stones featured stenosis at the confluence of left and both hepatic ducts (n = 2); and alternating dilatation and stenosis of left hepatic ducts and branches (n = 3). However, no statistical associations were observed between the hepatic ductal stenosis and cholangitis or stone formation (P = 0.153). CONCLUSIONS: Cystic-type biliary dilatations persist postoperatively, frequently accompanied by ductal stenosis. Alternating dilatation and stenosis is a common morphological feature for postoperative cholangitis and stones.

Usefulness of power Doppler ultrasonography and superparamagnetic iron oxide enhanced magnetic resonance imaging for diagnosis of focal nodular hyperplasia of the liver after treatment of neuroblastoma.

Focal nodular hyperplasia (FNH) of the liver is rare in children, and it is usually diagnosed through a biopsy of the liver or hepatectomy. The authors report a case of a 10-year-old girl with multiple focal nodular hyperplasia lesions of the liver after the completion of tumor therapy for advanced neuroblastoma, and review the usefulness of the combination of power Doppler ultrasonography (US) and superparamagnetic iron oxide (SPIO) enhanced magnetic resonance imaging (MRI) for the diagnosis of FNH without a biopsy of the liver or hepatectomy.

Effect of combined treatment with FK506, FTY720, and ex vivo graft irradiation in rat small bowel transplantation: expression of mucosal addressin cell adhesion molecule-1.

We studied the effect of the combined treatment with FK506, FTY720, and ex vivo graft irradiation. Five groups of SBT animals were studied on days 3, 5, and 7 after operation (untreated, FK506, FTY720, FK506 + FTY720, FK506 + FTY720 + irradiation). Indirect immunoperoxidase staining was performed against CD4 and MAdCAM-1. The numbers of CD4 positive cells in allografts were also analyzed by flow cytometry. The graft survival was prolonged in all of the FK506- and FTY720-treated groups. SBT allografts treated by FK506 and FTY720 demonstrated less infiltration of CD4 positive cells, but the irradiation group did not show any effects on its expression. In FK506- and FTY720-treated groups, MAdCAM-1 expression on the HEVs in PPs was up-regulated, and its expression on the ECVs in the LP was down-regulated compared with other allograft groups. Irradiation did not show any effects on MAdCAM-1 expression on both HEVs in PPs and ECVs in LP. FK506 and FTY720 prevented the infiltration of CD4 positive cells, the down-regulation of MAdCAM-1 expression on HEVs in PPs, and the up-regulation of MAdCAM-1 expression on ECVs in LP during the early phase of SBT.

Mesenchymal hamartoma of the liver originating in the caudate lobe with t(11;19)(q13;q13.4): report of a case.

We herein report the case of a 35-month-old female child presenting with mesenchymal hamartoma of the liver (MHL), with t(11;19)(q13;q13.4) originating in the caudate lobe. This case is the eighth known description of a cytogenetic abnormality in mesenchymal hamartoma of the liver. It is similar to the seven cases previously reported, in that one of the breakpoints involves the chromosome band 19q13.3 or 19q13.4, but it is the first report of an abnormality originating in the caudate lobe.

A rare case of multiple duodenal perforations in early infancy.

Duodenal perforation in early infancy is an uncommon condition. We describe a case of duodenal perforation from suspected ulcer. A premature boy was born at the gestational age of 26 weeks with a birth weight of 764 g. The Apgar score at 1 min was 3 and at 5 min had decreased to 2. He was given intermittent mandatory ventilation for one month after the birth. Ninety-eight days after birth, the infant's abdomen became distended. A supine and cross-table lateral radiograph of the abdomen revealed massive pneumoperitoneum. An exploratory laparotomy was performed, which revealed two perforations in the anterior wall of the first portion of the duodenum. The operation procedure was direct closure and intra-abdominal drainage. On the postoperative first day, he had central urorrhagia from hematencephalon. The patient's growth after surgery has been normal, with no recurrence of duodenal ulcer.

Usefulness of color doppler sonography and 99m Tc-RBC scintigraphy for preoperative diagnosis of a venous malformation of the small intestine in a 2-year-old child.

Venous malformations of the small intestine are rare in children, and the preoperative diagnosis of a venous malformation in the small bowel can be very difficult. We report the case of a 2-year-old girl with a solitary cavernous venous malformation of the small intestine that caused gastrointestinal bleeding and anemia and review the usefulness of the combination of color Doppler sonography and 99m Tc-RBC scintigraphy for the diagnosis of venous malformation of the small intestine.

Effect of FTY720 and ex vivo graft irradiation in rat small bowel transplantation: expression of mucosal addressin cell adhesion molecule-1.

PURPOSE: We performed a semiquantitative analysis of the expression of Mucosal addressin cell adhesion molecule-1 (MAdCAM-1) and gut-associated tissues (GALT) during small bowel graft rejection in the rat to confirm the effect of FTY720 and ex vivo graft irradiation. METHODS: Small bowel transplantations (SBT) were performed from BN rats to LEW rats. Four groups of SBT animals were studied on days 3, 5, and 7 after operations (untreated, FTY720, ex vivo graft irradiation, FTY720+ex vivo graft irradiation). Indirect immunoperoxidase staining was performed against CD4 and MAdCAM-1. The number of CD4-positive cells in the allografts was also analyzed by flow cytometry. RESULTS: The graft survival was prolonged only in the FTY720-treated groups. The SBT allografts treated by FTY720 demonstrated less infiltration, but the ex vivo graft irradiation group did not show any effect on its expression. In the FTY720-treated groups, MAdCAM-1 expression on high endothelial venules (HEVs) in Peyer's patches (PPs) was upregulated and its expression on endothelial cells of vessels in the lamina propria was downregulated in comparison with the allograft group without FTY720. CONCLUSIONS: It is important to prevent the infiltration of CD4-positive cells, the downregulation of MAdCAM-1 expression on HEVs in PPs and the upregulation of MAdCAM-1 expression on endothelial cells of vessels in the lamina propria for the prolongation of graft survival.

Intraoperative radiation therapy for advanced neuroblastoma: the problem of securing the IORT field.

The purpose of this study is to evaluate the efficacy of intraoperative radiation therapy (IORT) and the problem of securing the IORT field in advanced pediatric neuroblastoma. Between 1996 and 2005, 12 children received IORT for advanced pediatric neuroblastoma patients. Electron beam energies ranged from 10 to 12 MeV and median dose was 10 Gy (8-12 Gy). All of them had surgery with IORT against the primary tumor site and the abdominal aorta surroundings. A gross total resection (GTR) was achieved in 10 patients and subtotal resection (STR) was two patients. All of 12 patients were classified as high risk. Nine patients were alive 17-120 (mean 48 months) after diagnosis. Local tumor control was achieved in 100% of patients, of whom one experienced local recurrence outside the IORT field. At the operation, it was difficult to secure the IORT field because of the angle of the radiation cylinder in three patients. One of the three of these patients experienced local recurrence outside of the IORT field in the upper side of superior mesenteric artery and two of three patients had an external beam radiation after surgery, and there was no local recurrence. One patient had a postoperative ileus, and one patient had transient diarrhea and hydronephrosis. For advanced neuroblastoma patients, IORT produced excellent local control after surgery. However, there is a problem of securing the IORT field. For local control, it is necessary to add an external beam radiation after IORT when it is difficult to secure the IORT field.

Treatment of fistula-in-ano in infants with a seton.

Anal fistula in infants is a common disease. Although many are recovered by conventional treatment, there are some patients who are not repaired easily. We performed the seton method to an anal fistula and report the good result that we obtained.

Intussusception in children of school age.

BACKGROUND: There are only a few reports discussing the characteristics of intussusception developing in school-age children. The characteristics of these cases are discussed, with reference to previous literature. METHODS: The present study included eight cases of intussusception in school-age children among 143 intussusception patients treated on an inpatient basis at Nihon University Itabashi Hospital, during the 11 year period from 1993 to 2003. The remaining 135 patients were assigned to the infant group as controls. The clinical characteristics of intussusception in school-age children were compared with those of the condition developing in infants. RESULTS: The eight children of school age with intussusception ranged in age from 8 to 15 years (mean, 11.6 years), and consisted of five boys and three girls. The major symptom was abdominal pain, occurring in 100% (8/8). Bloody stools and vomiting were reported in two patients each (25%) from this group. The triad of abdominal pain, bloody stools and vomiting was recognized in only one child (12.5%) of this group. Two children (25.0%) had a palpable abdominal mass, and one child (12.5%) complained of diarrhea. None of the school-age children with intussusception had any antecedent infection; five, two and one patients had the ileo-colic type, ileo-ileo-colic type and ileo-ileal type of intussusception, respectively. Four underwent enema reduction and four underwent surgical reduction. One of the eight children (12.5%) had underlying organic abnormality; in the remaining children the condition was labeled idiopathic. One child developed recurrences. CONCLUSIONS: In school-age children intussusception is generally believed to be commonly secondary to underlying organic abnormality, but in the present study only one of eight school-age children had underlying organic abnormality; in the remaining children, the condition was labeled idiopathic. The major symptom in school-age intussusception was abdominal pain. Therefore this may need to be differentiated from appendicitis in children of school age. It is considered that abdominal ultrasonography (USG) is a simple and useful method for making the diagnosis of intussusception, and that diagnostic USG should be conducted in all school-age children presenting with acute abdominal pain.