Surgical tricks of handling a needle and grasping forceps during laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia.

INTRODUCTION: Laparoscopic percutaneous extraperitoneal closure (LPEC) is an alternative to open repair for pediatric inguinal hernias; however, its application for boys remains controversial. In this study, we developed a technique to enhance the safety and feasibility of LPEC. MATERIAL AND SURGICAL TECHNIQUE: In our technique, forceps are used to pull up the peritoneum ahead on the route, creating a space between the peritoneum and structures, including gonadal vessels and vas deferens. This potentially decreases the risk of perioperative injury of these structures. This technique also allows the needle to pass on the shortest course around the inguinal ring without crossing the vas deferens, possibly lowering the likelihood of injury and preventing excessively high ligation of the vaginalis process. DISCUSSION: Our technique diversifies the LPEC methods, thereby augmenting the feasibility and safety of the procedure.

Efficacy of adhesive strapping on umbilical hernia in children: a systematic review and meta-analysis of cohort studies.

Background: Although adhesive strapping (AS) for pediatric umbilical hernia (UH), which was once obsolete, has been reconsidered as a common practice in Japan, its efficacy is still unclear. This study aimed to evaluate its efficacy by reviewing related articles. Methods: A comprehensive literature search of PubMed, Cochrane, Google Scholar, and Igaku Chuo Zasshi via Ichushi-Web was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Cohort studies reporting on the UH closure rate after AS compared with observation-only management were included. Results: A total of 10 cohort studies were included, and the overall UH closure rate was not statistically significant (p=0.31, risk ratio (RR)=0.76, 95% confidence interval (CI) 0.45 to 1.28). However, there were significant differences in the UH closure rate at the age of 6 months (p<0.01, RR=0.55, 95% CI 0.41 to 0.75) and the efficacy of preventing protruding umbilici with redundant skin (p=0.049, RR=0.16, 95% CI 0.03 to 0.99). Conclusions: Although the efficacy of AS on UH compared with observation-only management did not differ in terms of the UH closure rate, the application of AS may be effective for faster UH closure and the prevention of protruding umbilici. However, due to the high heterogeneity of the study, further large-scale studies, particularly randomized controlled trials, are warranted to reach a conclusion. PROSPERO registration number: CRD42022314417.

Hepatoblastoma with multiple tumors in a school-aged child.

Clinicians need to consider hepatoblastoma in the differential even in school-aged children or adolescents presenting with multiple liver tumors.

Forkhead box P3 (FOXP3) mRNA expression immediately after living-donor liver transplant.

OBJECTIVES: The forkhead box P3 (FOXP3) gene is considered to be the master gene of regulatory T cells. The significance of regulatory T cells in liver transplant has been investigated in previous reports, but quantitative FOXP3 messenger RNA (mRNA) expression after living-donor liver transplant has not been assessed. The objective of this study was to determine whether the human FOXP3 gene is a good marker for regulatory activity in T cells in living-donor liver transplant recipients during the immediate posttransplant period. MATERIALS AND METHODS: In peripheral blood mononuclear cells of 15 living-donor liver transplant recipients during the first month after transplant; we measured the population of CD4+CD25+ T cells using flow-assisted cell sorting and the expression of FOXP3 mRNA using real-time polymerase chain reaction. RESULTS: Fold induction of FOXP3 mRNA significantly increased on postoperative day 7 (3.3-fold) compared with the reference preoperative value (P < .01) but returned to baseline by 28 days after transplant. The population of CD4+CD25+ T cells did not change significantly. Expression of FOXP3 mRNA on days 14, 21, and 28 were lower in recipients with acute cellular rejection within 60 days after living-donor liver transplant. CONCLUSIONS: Increased expression of FOXP3 mRNA immediately after living-donor liver transplant might be influenced by activation of T cells including regulatory T cells and other T cells. However, after stabilization of these activation profiles, it seems likely that FOXP3mRNA expression is associated with graft acceptance. Further studies are necessary with measurement of FOXP3 mRNA expression at appropriate sampling points.

[Current status and perspective of pediatric liver transplantation in Japan].

In Japan, the annual number of pediatric liver transplantation (LT) has been stable around 140 in the last few years. Almost all of them are from living donors. Three fourth are indicated for cholestatic liver diseases, mainly biliary atresia. One year patient survival rate after pediatric LT in Japan is 85 %. In comparison to other indications, patient survival of the infants with fulminant hepatic failure is quite poor. Weaning protocol of immunosuppression in pediatric LT in Japan is going in many institutions, and has succeeded to obtain some number of recipients with complete tolerance. More attenuated immunosuppresion and intimate monitoring for EB virus infection using the real-time PCR has been effective to decrease the incidence of post-transplant lymphoproliferative disorder.

Duct-to-duct biliary reconstruction in pediatric living donor liver transplantation.

The results of duct-to-duct biliary reconstruction in six pediatric patients who received a living donor liver transplant aged from 2 months to 11 yr old are reported. The graft was either entire or a part of the left lateral segments. The orifice of the bile duct of the graft was anastomosed to the recipients' hepatic duct in an end-to-end fashion by interrupted suture using 6-0 absorbable material. A transanastomotic external stent tube (4 Fr) was passed through the stump of the recipients' cystic duct. Mean time for reconstruction was 24 min. All the recipients survived the operation and reinitiated oral intake on postoperative day 3. There were no early biliary complications. One 5-yr-old boy suffered from an anastomotic stenosis 9 months after transplantation. He underwent re-anastomosis by Roux-en Y (R-Y) procedure and recovered uneventfully. Duct-to-duct anastomosis in pediatric living donor liver transplantation has benefits while the complication rate is comparable to R-Y reconstruction.