Experience of Open Herniorrhaphy Using the PerFix(R) Plug for Patients with Recurrent Groin Hernias

PURPOSE: The recurrence of a groin hernia presents few surgical options for repair. We investigated the safety and efficacy of herniorrhaphy using PerFix(R) plug for patients with recurrent groin hernias. METHODS: Between October 2000 and December 2004, 30 herniorrhaphies for recurrent groin hernia were performed and followed-up. The operation time, length of hospital stay, time of analgesic use, complication rates, and recurrence were investigated. RESULTS: Surgery had been initially performed in 26 patients with the non-mesh method, and with mesh in 4 patients; 12 patients had a direct recurrence at the medial side of the inguinal area near the pubic tubercle, 7 patients had a direct recurrence at other sites, and 11 patients had an indirect recurrence. Eight patients had urinary retention and 2 patients had minor wound complications. Hospital stays and analgesic use were comparable to non-recurrent groin hernia operations, although operation time was significantly longer in recurrent group, and there were no recurrences during the 70 months of followup. CONCLUSION: Comparing open or laparoscopic preperitoneal approach, the PerFix(R) plug method is simple and effective for recurrent groin hernia repair.

Outcome of Patients Undergoing Kasai Procedure for Biliary Atresia: a Study of Those Surviving More Than 10 Years with Their Native Livers

To evaluate the long-term prognosis of biliary atresia after Kasai operation, a total of 14 patients (of the 41 patients operated upon from 1982 to 1997), who had been followed up for more than 10 years, were included in this retrospective study. Eleven out of 14 patients survived with their native livers, and their data analyzed for age at operation, clearing time of jaundice, histological outcome, postoperative complications, effectiveness after the application of an intussusception anti-reflex valve, and quality of life. Average age at surgery was 62.8 days. Serum bilirubin was normalized within three months in all patients. Six among the eleven long-term survivors had ascending cholangitis as one of the postoperative complications. The application of an intussusception anti-reflux valve did not show any statistical significance in long-term survival. Most of long-term survivors appeared to enjoy good quality of life. Kasai operation might not be the definitive treatment for biliary atresia; however, Kasai operation made it possible to achieve long-term survival for patients with biliary atresia when the patients were detected and treated as early as possible.

Clinical Analysis of Choledochal Cysts in Children

PURPOSE: The object of this study is to evaluate the clinical findings and the outcome of choledochal cysts (CC) in children. METHODS: All cases of CC that underwent operation between 1983 and 2006 were studied retrospectively. We evaluated the symptoms and signs, types, anomalous pancreaticobiliary union (APBDU) and complications of CC. RESULTS: Forty-five children were included. The common age range was from 1 year to 5 years. The male to female ratio was 1 to 3. The most common symptom was abdominal pain (71.1%). The main methods of diagnosis were US and CT. According to Todani's classification, type I (60%) and type IV (35.6%) were most common types. APBDU was confirmed in 21 cases. B-P type (13 cases) was more common than P-B type (8 cases). Three among four patients with pancreatitis had a stone or protein plug in the common channel. Cyst excision with hepaticojejunostomy was performed in most cases. The overall morbidity and mortality were 8% and 0%, respectively. There were no problems, such as cholangitis, biliary stone and biliary cancer during the follow up. Intrahepatic duct dilatations of type IVa disappeared in the postoperative follow up study, except one. CONCLUSION: The outcome of cyst excision with hepaticojejunostomy was excellent. As for CC accompanied with the pancreatitis, the presence of stone or protein plug in the common channel needs to be examined. It is hard to precisely interpret that intrahepatic duct dilatation in type IVa normalize during the postoperative follow up until more evidence is accumulated.

Esophageal Atresia with Tracheoesophageal Fistula: A 20 Year Experience of 51 Cases

The aim of this study is to analyze the outcomes of the esophageal atresia with tracheoesophageal fistula over the last 2 decades. The records of 51 patients born between 1987 and 2006 were reviewed. Twenty-seven patients were male. Mean values of the age, gestational age and birth weight were 2.9 days, 296 days and 2.7kg, respectively. All patients had Gross type C anomalies. Thirty-one patients (60.7 %) had one or more associated congenital anomalies and the most common anomaly was cardiac malformation. In 48 cases, primary anastomosis was done and staged operation was done in one case. Circular myotomies in the proximal esophagus were performed in 9 cases. Postoperative complication developed in 26 cases (54 %): pulmonary complication in 12 cases, anastomotic leakage in 10 and anastomotic stricture in 10, recurrent trachoesophageal fistula in one and tracheomalasia in 2 cases. Reoperation was carried out in 2 patients with anastomotic leaks, the remaining leaks were managed non operatively. Three of the strictures were reoperated upon and the others were successfully managed by balloon dilatations. Overall mortality rate was 15.6 %. Mortality rate of the second 10 years (8 %) period decreased significantly compared to that of the first 10 years (23 %) period.

Recurrent Lipoblastoma of the Chest Wall in a Child

Lipoblastoma is a relatively rare benign tumor that occurs in infancy and early childhood, and it arises from embryonic white fat. It is classified into two forms based on pathologic features: benign lipoblastoma is a superficial, well-defined mass and diffuse lipoblastomatosis is a deep, infiltrative lesion. They are both histologically benign, but local recurrences can happen without any tendency of metastasis. The prevalent sites are chiefly the upper and the lower extremities and less commonly the head, neck, trunk, mesentery, mediastinum, and retroperitoneum. The treatment of choice is surgical excisions, and the prognosis is good, but recurrence is possible in the case of incomplete excision, so wide local excision is preferred. We experienced a locally recurrent lipoblastoma in an 8 month old female child in the chest wall that reoccurred three months after the primary excision. Because 9th and 10th rib invasion was suspected on magnetic resonance imaging study, mass excision along with partial 9th and 10th ribs resection was performed. The histologic diagnosis confirmed lipoblastoma.

Experience with Tapering Enteroplasty in Intestinal Atresia

Tapering enteroplasty was first described by Thomas in 1969 as one method of intestinal anastomosis. The advantages of tapering enteroplasty in the intestinal atresia are: First, it makes end-to-end anastomosis possible between the atretic bowel ends with considerable differences in diameters. Second, it promotes the recover of the postoperative bowel function. Third, it prevents the possibility of the short bowel syndrome by eliminating the need of resecting the dilated bowel. A total of 22 patients with intestinal atresia who underwent tapering enteroplasty from January 1988 to December 2005 at our institute were reviewed. In 3 of 22 cases, tapering enteroplasty was the 2nd operation after an initial end-to-oblique anastomosis. We reviewed the following items: age, sex, type and location of intestinal atresia, initial feeding and total enteral feeding start day, the length of hospital stay and complications. The average age of the patients was 7 days. Male to female ratio was 1 to 1.2 (10 cases: 12 cases). We performed the tapering enteroplasty on all types and locations of the intestinal atresia from the duodenum to the colon: type I (n=3), type II (n=4), type IIIA (n=7), type IIIB (n=5), type IIIB and IV (n=1), type IV (n=1) and type C (duodenum) and type IIIB and IV (jejunum). On the average, the oral feeds were started on the postoperative 8.8th day, and full caloric intake via the enteric route was achieved on postoperative 13.3th day. The average length of hospital stay was 19.6 days. There were 1 case (4.5 %) of anastomotic complication and 2 cases (9 %) of adhesive ileus among 22 patients. The tapering enteroplasty on all types of intestinal atresia is a usefull operative method when there are considerable diameter differences between the atretic bowel ends.

Clinical Analysis of Vitelline Duct Anomalies in Children

A vitelline duct (VD) anomaly is a relatively common congenital abnormality of the umbilical area. The anomalies include patent vitelline duct (PVD), cyst, fistula or sinus. The incidence is approximately 2% of the populations, but development of symptoms is rare. Recently, we experienced two cases; PVD accompanied by a smallomphalocele and intestinal volvulus due to mesenteric band between Meckel's diverticulum and the mesentery. Thereafter,we evaluated the data of vitelline duct anomalies for 27 years. From 1980 to 2006, 18 cases of VD anomalies were reviewed based on the hospital records retrospectively. There were 15 boys and 3 girls and age ranged from 2 days to 15 years. Among the 18 cases, 15 cases were symptomatic and consisted of Meckel's diverticulum (10 cases), PVD (4 cases) and umbilical polyp (1 case). Three asymptomatic cases of Meckel's diverticulum were found incidentally were and were observed without resection. Ten cases of Meckel's diverticulum were presented with intestinal bleedings (4 cases), intestinal obstructions (5 cases) and perforation (1 case). Wedge resections and segmental resections of ileum were performed in 8 patients and 2 patients, respectively. Postoperative complications were adhesive ileus (1 case) and wound seroma (1 case). Small omphaloceles were accompanied in two of 4 PVD patients. There was 1 small omphalocele case which was accompanied by a prolapse of ileum. In summary, VD anomalies were more common in male and more than half of them were found in patients less than 1 year of age. PVD was diagnosed most frequently in neonates. Meckel's diverticulum presented with intestinal obstruction more frequently than bleeding.

Tension-free Herniorrhaphy Using PerFix(R) Plug: A Follow-up Report

BACKGROUND: Since the mid-1990s, PerFix(R) plug hernioplasty has become one of the mainstays of hernia surgery. We previously reported the preliminary results of the PerFix(R) plug hernioplasty in 2003. Here we report the results of a 5 year follow-up study of PerFix(R) plug hernioplasty. METHODS: From May 2000 to April 2005, 326 PerFix(R) plug repairs were performed. The operation times, lengths of hospital stay, visual analogue pain scales, time of analgesics use and complications and recurrence rates were evaluated prospectively. RESULTS: 326 cases underwent mesh-plug hernioplasties, 285 with inguinal hernias primary, 35 with recurrent hernias and 6 with femoral hernias. 218 and 101 cases were indirect and direct hernias, respectively. The mean age was 59.8 years. The male to female ratio was 289 : 15. Cardiovascular disease is the most common associated disease. The mean operation time was 31 minutes. The mean length of hospital stay was 2.5 days. The mean length of analgesics use, acetaminophen (1T: 300 mg p.o) and Nubaine (5 mg IM), were 1.89 and 0.5, respectively. Seventy-six (23%) cases developed a postoperative complication with urinary retention being the most common. During the follow up period from 12 months to 6 years, the overall recurrence rate was 0.6% (n=2). CONCLUSIONS: Tension-free repair of an inguinal hernia by PerFix(R) plug is a simple and secure method with less pain, quick operation times, short hospital stays, low complication rates and low recurrence rates.

Trend (in 2005) of Repair of Inguinal Hernia in Children in Korea : A National Survey by the Korean Association of Pediatric Surgeons in 2005

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.

Hereditary Pancreatitis: Report of a Kindred

Hereditary pancreatitis (HP) appears as an autosomal dominant trait. If the patient has (1) more than 2 affected relatives in different generations and (2) no known etiological factors such as alcohol or gallstones, or has R122H or N29I mutation in the cationic trypsinogen (CT) gene, the diagnosis of HP can be applied. Risk of pancreatic cancer is estimated to be 53-fold higher than in a general population after the age of 50 years. We report a kindredof HP, involving three of its family together; two siblings (14 years old, 13 years old) and cousin (26 years old). The patient had complicating chronic pancreatitis and pancreatic stone, and was treated with amodified Puestow-Gillesby procedure. Her sisters showed chronic pancreatitis. Her cousin underwent a drainage procedure of the pancreatic duct for chronic pancreatitis during the high school period. All the three members showed the R122H mutation of the CT gene.

Hereditary Pancreatitis: Report of a Kindred

Hereditary pancreatitis (HP) appears as an autosomal dominant trait. If the patient has (1) more than 2 affected relatives in different generations and (2) no known etiological factors such as alcohol or gallstones, or has R122H or N29I mutation in the cationic trypsinogen (CT) gene, the diagnosis of HP can be applied. Risk of pancreatic cancer is estimated to be 53-fold higher than in a general population after the age of 50 years. We report a kindredof HP, involving three of its family together; two siblings (14 years old, 13 years old) and cousin (26 years old). The patient had complicating chronic pancreatitis and pancreatic stone, and was treated with amodified Puestow-Gillesby procedure. Her sisters showed chronic pancreatitis. Her cousin underwent a drainage procedure of the pancreatic duct for chronic pancreatitis during the high school period. All the three members showed the R122H mutation of the CT gene.

Congenital Infantile Fibrosarcoma

A newborn male baby was transferred to our hospital with a left inguinal mass. The mass was huge measuring 10 x 10 cm, engorged, and dark-blue colored as a result of internal hemorrhage. Unstable vital signs were combined with DIC and acute renal failure. Emergency operation was performed because of the suspicion of bowel perforation. The peritoneal cavity was full of ascitis and the distal jejunum had a 0.5 cm perforation. Segmental resection of the jejunum and incisional biopsy of the inguinal mass were performed. On pelvic and thigh MRI, the mass protruded into pelvic cavity and encircled large vessels and nerves of the thigh. Pathologic diagnosis was congenital infantile fibrosarcoma. Fifteen days after operation, primary tumor excision was undertaken. The second look operation, performed after 6 times VAC chemotherapy, revealed no remained malignant cell on microscopic section. The baby has been followed closely for the last eight months.

A Clinical Score and Ultrasonography for the Diagnosis of Childhood Acute Appendicits

Diagnosis of acute appendicitis in children is sometimes difficult. The aim of this study is to validate a clinical scoring system and ultrasonography for the early diagnosis and treatment of appendicitis in childhood. This is a prospective study on 59 children admitted with abdominal pain at St. Mary's Hospital, the Catholic University of Korea from July 2002 to August 2003. We applied Madan Samuel's Pediatric Appendicitis Score (PAS) based on preoperative history, physical examination, laboratory finding and ultrasonography. This study was designed as follows: patients with score 5 or less were observed regardless of the positive ultrasonographic finding, patients with score 6 and 7 were decided according to the ultrasonogram and patients above score 8 were operated in spite of negative ultrasonographic finding. The patients were divided into two groups, appendicitis (group A) and non-appendicitis groups (group B). Group A consisted of 36 cases and Group B, 23 cases. Mean score of group A was 8.75 and group B was 6.13 (p<0.001). Comparing the diagnostic methods in acute appendicitis by surveying sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, PAS gave 1.0000, 0.3043, 0.6923, 1.0000, and 0.7288, and ultrasonography gave 0.7778, 0.9130, 0.9333, 0.7241, and 0.8300 while the combined test gave 1.0000, 0.8696, 0.9231, 1.0000, and 0.9490, respectively. Negative laparotomy rate was 3 %. In conclusion, the combination of PAS and ultrasonography is a more accurate diagnostic tool than either PAS or ultrasonography.

The Adequacy of Laparoscopic Appendectomy for Simple and Perforated Appendicitis in Children

Appendectomy is the most common emergency surgical operation in children. The laparoscopic treatment of pediatric appendicitis is controversial, particularly in complicated cases. The purpose of this study is to evaluate laparoscopic appendectomy (LA) and open appendectomy (OA) for simple and perforated appendicitis (SA, PA) in children. A total of 188 patients, operated from January 1992 to September 2003, were reviewed. Ninety-one patients underwent OA (65 SA and 26 PA) and 97 had LA ( 67 SA, 30 PA). There was one conversion of LA to OA in PA. Operative time for LA was longer for OA in PA (55.8 vs. 45.7 min; p=0.0467). Recovery of bowel movement, diet starting time, length of hospital stay for LA were significantly shorter than those for OA. Postoperative complication rate was not different between LA and OA in each group. Laparoscopic appendectomy is a safe and effective method for both simple and perforated appendicitis.

Biliary Atresia with Extrahepatic Biliary Cyst

Biliary atresia (BA) with extrahepatic biliary cysts (EHBC) is a rare disease. It has been generally recognized as type I (correctable with cystic dilatation), which means a good prognosis. From a total of 73 patients with BA who underwent operation from September 1988 to September 2003 at our institute, 7 (9.6 %) cases of type III BA with EHBC (uncorrectable with cystic dilatation) are reviewed. Clinical findings, laboratory data, radiologic findings, treatment methods and outcomes were reviewed. Female was more prevalent (male to female ratio; 2:5). All cases were type III with EHBC according to the intraoperative cholangiography, and underwent Kasai's portoenterostomy. The mean age was 57 days at operation. Three patients(42.9 %) are long term survivors. Further evaluation is needed to determine the correlation between prognostic factors and outcome for.

Tension-free Herniorrhaphy Using PerFix(R) Plug: A Preliminary Report

PURPOSE: The PerFix(R) plug is preformed as a Marlex mesh hernia plug, and consists of a fluted outer layer combined with an inner arrangement of eight mesh "petals." In contrast to hand-rolled hernia plugs, which can collapse on themselves, the PerFix(R) plug's petals maintain the device's open conelike shape. The fluted design allows the plug to more readily conform to the configuration of any indirect or direct defect. METHODS: Bewteen January 1996 and April 2000 126 conventional herniorrhaphies (C group: Bassini: 23, Shouldice: 15, McVay: 5, Lichtenstein: 83) were performed, and between May 2000 and April 2002, 124 PerFix(R) plug repairs (P group) were completed. The operation times, lengths of hospital stay, visual analogue pain scales, time of analgesics use, and complication and recurrence rates were compared between these two groups. RESULTS: The operation times and lengths of hospital stay for groups C and P were 56.4 vs. 31.1 minutes and 4.4 vs. 2.8 days, respectively, so where significantly shorter in the P group (P<0.01). The times of use for the analgesics, AAP and Nubaine, were 6.6 vs. 0.6 times and 1.7 vs. 0.9 times, in group C and P, respectively, so were significantly fewer in the P group (P<0.01). There were 5 recurrences (3.9%) in the C group during the follow up period (2~6 years), but there were none in the P group during the follow up period (5 months~2 years). The complications were similar in both groups. CONCLUSION: Compared with conventional surgical techniques, including the Lichtenstein tension free method, the PerFix(R) plug method is the most simple, and shows superiority in the following areas; the operation time, length of hospital stay, times of analgesics use and recurrence. However, with regard to the recurrence, longer follow up and observation periods are required.

Colonic Complication of Acute Necrotizing Pancreatitis: a Case Report

We present a case of a colonic involvement associated with necrotizing pancreatitis, with a review of the literature. A 10 year old boy had an appendectomy at the local clinic ten days ago. On admission, he complained nausea, vomiting and severe constipation. His abdomen was distended and he had tenderness on the left abdomen. Laboratory and radiologic studies revealed findings consistent with acute pancreatitis with colonic complication. He was treated conservatively for 30 days but did not improve. On hospital 30th day, abdominal pain developed and his vital sign changed. Abdominal CT suggested ischemic change of the transverse colon. At laparotomy, the left colon showed stenosis. The greatly distended transverse colon was resected and a transverse end colostomy was done. He was discharged at postoperative 45th day with improvement and colostomy closure was performed 8 months later.

Diffuse Cavernous Hemangioma of the Rectosigmoid Colon: a Case Report

Diffuse cavernous hemangioma of the rectosigmoid is a rare lesion usually presented in children and young adult, often with life threatening hemorrhage. The clinical diagnosis is difficult and often delayed because of lack of awareness of the clinical features. We report a case of diffuse cavernous hemangioma of the rectosigmoid in a 12-year-old boy who had undergone suture ligation under the impression of hemorrhoid at his age 3. Sphincter-saving coloanal pull through procedure were applied as the surgical treatment. Sclerotherapy was needed with recurrent rectal bleeding 6 months after the pull through operation. The patient is well at 12 months follow-up.

Right Congenital Posterolateral Diaphragmatic Hernia

Congenital right posterolateral diaphragmatic hernia is rare. Moreover, cases of delayed presentation are extremely rare. We experienced two cases of right posterolateral diaphragmatic hernia. One case was a 1 day old male neonate with cyanosis. He was diagnosed as a congenital right posterolateral diaphragmatic hernia by chest X-ray and repaired primarily through trans-abdominal approach. There was a 54 cm defective area at the right posterolateral diaphragm. The right lobe of the liver, gall bladder, small intestine and right colon were herniated though the defect into the thoracic cavity. The patient was supported by mechanical ventilation for 1 month and was discharged without complication on the 41st day. The other case was an 11-month male infant with dyspnea, cough and seizure. He was diagnosed with delayed presentation of congenital right posterolateral diaphragmatic hernia by chest X-ray and repaired primarily through transabdominal approach. Almost all of the small intestine and right colon were herniated through a 54 cm sized posterolateral defect in the right diaphragm. He didn't need postoperative ventilatory support and was discharged without complications on the ninth day.

Mesenteric and Omental Cysts in Children

Mesenteric and omental cysts are rare intra-abdominal lesions in childhood, and may present various clinical features such as an asymptomatic mass or an acute abdomen. Therefore, these entities are frequently misdiagnosed preoperatively or are found only incidentally at operation for other conditions. We analyzed our experiences of 19 cases in a 19 year period from 1981 to 1999, at College of Medicine, Catholic University of Korea. There were 12 boys and 7 girls with a mean age of 4.8 years (range, 3 days to 15 years). Common presenting symptoms were abdominal pain (47%), abdominal distension (31%), abdominal mass (24%), vomiting (15%) and fever (10%). Ultrasonography was the most preferred method of diagnosis. Other diagnostic modalities include CT, MRI, and abdominal ascites tapping in selected patients. Location of the mesenteric cysts was small bowel mesentery in nine, the right mesocolon and retroperitoneum in one, the left mesocolon in one, and the jejunum, sigmoid-colon mesentery in one. Most of the patients underwent cyst excision, but six patients required concomitant bowel resection for complete removal of the lesions, and two patients underwent unroofing and simple aspiration respectively. There was one mortality case due to sepsis.