A pediatric case of Burkitt's lymphoma with bile duct obstruction requiring surgical biliary reconstruction.

BACKGROUND: Biliary obstruction due to compression by a B-cell solid tumor occurs rarely. A few reports have described biliary reconstruction surgery for obstructive jaundice caused by Burkitt's lymphoma. However, there are no detailed reports on pediatric cases. We report a pediatric case of obstructive jaundice due to malignant lymphoma treated with biliary reconstruction surgery. CASE PRESENTATION: A 5-year-old girl presented to our hospital with a massive abdominal tumor that caused biliary stricture. Chemotherapy was initiated after an open tumor biopsy. However, endoscopic biliary stent placement was performed owing to elevated bilirubin levels. We treated the patient with chemotherapy for 9 months while endoscopically replacing the biliary stent every few months. She achieved complete tumor remission. However, sclerotic lymph nodes were persistent on the dorsal side of the cholecystic duct junction, and biliary stricture at the same site had changed to stent-dependent biliary obstruction. Therefore, we performed choledochojejunostomy and retrocolic Roux-en-Y reconstruction 15 months after initial admission. There were no postoperative complications or tumor recurrences, and the bilirubin level remained low. Histopathologically, the resected bile duct wall was fibrotic and thick, and the bile duct lumen narrowed. CONCLUSIONS: Biliary reconstruction is effective to achieve long-term biliary patency in pediatric patients with stent-dependent biliary obstruction due to malignant lymphoma. However, the decision on when to stop biliary stent replacement and proceed to biliary reconstruction surgery is a matter of debate. Further case studies are required to address this issue.

Dye laser treatment for hemorrhagic vascular lesions.

BACKGROUND AND AIMS: It is generally thought that bleeding from a hemangioma is difficult to stop. With development of the long pulse dye laser (LPDL), it has become possible to treat hemangioma with a large blood vessel diameter. Thus, it is effective in treating infantile hemangioma and pyogenic granuloma. MATERIALS AND METHODS: Five patients who visited our hospital from July 2015 to July 2017 due to hemorrhagic hemangioma were treated using a flash lamp excitation pulse dye laser with parameters of 7 mm spot size, 3 msec pulse width, fluence 12-14J/cm2, DCD 30 msec, and delay 30 msec. RESULTS: The bleeding not only stopped, but the raised lesion was flattened in all cases. CONCLUSIONS: LPDL is effective for both infantile hemangioma and pyogenic granuloma. It not only stops bleeding, but also treats the vascular lesions.

Surgical exploration for impalpable testis: Which should be first, inguinal exploration or laparoscopic abdominal exploration?

PURPOSE: To discuss an optimal surgical approach for impalpable testis in children, our own treatment results and those reported in the literature were reviewed. MATERIALS AND METHODS: Seventy-two impalpable testes were diagnosed in 68 patients: unilateral in 64 patients and bilateral in 4 patients. All patients underwent surgical exploration at the ages of 6 to 140months (median, 15months). The inguinal canal was initially explored, and abdominal exploration was performed with laparoscopy when an extra-abdominal testis was not identified. In addition, articles regarding surgical exploration for impalpable testis, published over the last 20years, were retrieved and the results were examined. RESULTS: Testes were detected by inguinal exploration in 28 of 72 (39%) impalpable testes: intracanalicular in 22 testes and at the internal inguinal ring (peeping or low abdominal testis) in 6 testes. All these testes were treated by conventional inguinal orchidopexy. Laparoscopic exploration was performed in 44 (61%) impalpable testes, and 4 (5.6%) high abdominal testes were detected and treated by two-stage Fowler-Stephens orchidopexy. Vanishing or absent testis was the final diagnosis in the remaining 40 testes (55.6%). The literature review showed that the ratios of intra- and extra-abdominal testes were lower in the articles that reported the results of inguinal or scrotal exploration than in those of laparoscopic exploration, although the difference was not significant. CONCLUSIONS: Considering the relatively low incidence of high abdominal testis, we recommend to start with inguinal exploration for impalpable testis. When an extra-abdominal testis is not detected, transinguinal laparoscopic exploration should be indicated. LEVEL OF EVIDENCE: Treatment study, Level IV.

Successful living donor liver transplantation for giant extensive venous malformation.

We report our success in employing LDLT as a course of treatment for extensive hepatic VM. A 14-yr-old pediatric patient presented at our hospital with nosebleed, fatigability, orthopnea, and abdominal distension. He had a history of right hemicolectomy with primary anastomosis due to VM of the transverse colon at age seven. Coagulation abnormalities were apparent, characterized by high international normalized ratio of prothrombin time, decreased fibrinogen level, increased FDPs, and D-dimer. T2-weighted magnetic resonance imaging revealed numerous, variable-sized high signal intensity nodules. Abdominal ultrasonography and CT scan showed hepatomegaly with multiple hypo-echogenic lesions and arteriovenous shunting in the liver. Doppler ultrasound showed hypokinetic flow in the hypo-echogenic lesions of liver. Immediate LDLT was performed to avoid spontaneous rupture and DIC. The right lobe of the liver was implanted with temporary portocaval shunt to prevent intestinal congestion and bleeding. Pathologic examination of the explanted liver confirmed the presence of an extensive hepatic VM. The postoperative course was uneventful, and the patient remained symptom-free with normal liver function throughout the 12-month follow-up period.

Safety and efficacy of selective sac extraction method of inguinal hernia repair in children: results of a prospective study.

PURPOSE: A prospective study was conducted to confirm the safety and efficacy of the selective sac extraction method (SSEM) of inguinal hernia repairs in children. METHODS: Primary endpoints of the study were the incidence of any complication related to the SSEM, or hernia recurrence. Secondary endpoints included the success rate of the SSEM, length of incision at the end of operation, and duration of operation. The incidence of contralateral manifestation of hernia was also examined. RESULTS: Between October 2009 and December 2011, a total of 317 repairs, 145 male repairs and 172 female repairs, were performed by applying the SSEM. There were three operative conversions, and the success rate of the SSEM was 99% in both male and female patients. The length of incision ranged from 4.0 to 12.5 mm (median 6.0 mm) and was ≤7.0 mm in 93% repairs. The incisional length for male repairs ranged from 4.0 to 12.5 mm (median 6.0 mm) and was ≤7.0 mm in 86% repairs, while it ranged from 4.0 to 9.0 mm (median 5.5 mm) in female repairs and was ≤6.5 mm in 96% repairs. The duration of the operation for unilateral repair ranged from 9 to 66 min (median 21 min). Eighty percent of repairs were examined 6-44 months (median 12 months) after the operation. There was one (0.4%) recurrence among 250 repairs and two (1.7%) cases of testicular dislocation among 115 male repairs. Contralateral hernia presented in 19 (9.5%) of 199 patients with unilateral hernia who underwent the follow-up. CONCLUSIONS: The feasibility of the SSEM was reconfirmed, and it was revealed that the complication and recurrence rates were low and acceptable. The SSEM is safe and effective, and should be a standard method for repairing inguinal hernia in children.

Association of extrahepatic bile duct duplication with pancreaticobiliary maljunction and congenital biliary dilatation in children: a case report and literature review.

We herein report a case of cystic-type congenital biliary dilatation (CBD) in whom an extremely rare anomalous duplication of the common bile duct and pancreaticobiliary maljunction were diagnosed intraoperatively by meticulous surgical manipulations via conventional open surgery. By performing a dissection at the outer epicholedochal layer of the cyst, a thin cord-like structure shown to be the distal part of the common bile duct was identified. A further exploration revealed that the most distal (extra- and intrapancreatic) part of the common bile duct was duplicated, and each branch of the duct was connected to the main and accessory pancreatic ducts. The experience with our case and a literature review showed that extrahepatic bile duct duplication is generally associated with pancreaticobiliary maljunction and CBD. We conclude that an extremely careful exploration with delicate and meticulous surgical manipulation is essential to identify these morphological anomalies and prevent intraoperative and postoperative complications of CBD, such as pancreatic duct injury or pancreatitis.

[Diagnosis and treatment of acute appendicitis in children].

In this review article, we discussed the pathogenesis, pathophysiology, diagnosis and treatment of acute appendicitis in children. Indications for early surgery, the operative methods of laparoscopic appendectomy and the treatment outcome are also presented.

A selective sac extraction method: another minimally invasive procedure for inguinal hernia repair in children: a technical innovation with satisfactory surgical and cosmetic results.

PURPOSE: To achieve satisfactory surgical and cosmetic results with minimal surgical invasiveness without laparoscopic assistance in childhood inguinal hernia repair, a novel technique, the selective sac extraction method (SSEM), was devised. The technical feasibility of this method was retrospectively examined. METHODS: The method was applied to 162 consecutive hernia repairs in 153 patients, 79 boys and 74 girls, excluding patients with incarcerated or irreducible hernia, sliding hernia of the ovary (hernia with palpable ovary at repair), or hernia associated with an undescended testis. Hernia repair was performed by several young surgeons under the guidance of one teaching surgeon. RESULTS: Patients' ages ranged from 1 month to 12 years (median, 3 years), and their body weights ranged from 2.9 to 41 kg (median, 14.4 kg). The SSEM was accomplished in 149 (92%) of 162 repairs, and lengths of incision at the end of the procedure were less than 10 mm in all repairs. The success rate was 72 (88%) of 82 repairs in male patients and 77 (96%) of 80 repairs in female patients. In the remaining 13 (8%) repairs in 13 patients, 10 males and 3 females, the procedure was converted to a conventional open method by extending the incision to 10 mm or longer. The ages of the 13 patients ranged from 1 month to 8 years (median, 3 months), being significantly younger than patients whose repair was accomplished by the SSEM (P = .006). The reason for conversion in 9 repairs was a huge or thickened sac that could not be extracted from the small incision, of which 6 involved male infants younger than 11 months. Obesity (the body mass index was 22.2 and >97th percentile for the patient's age) and thick subcutaneous tissue characteristic of early infancy were also reasons, both of which hindered the approach to the inguinal canal. Other reasons included malpositioning of the skin incision and difficulty in sac identification. The lengths of incision at the end of the 162 repairs ranged from 4.5 to 13.0 mm (median, 7.0 mm). Those in female patients, 4.5 to 11.5 mm (median, 6.5 mm), were significantly shorter than in male patients, 5.0 to 13.0 mm (median, 7.5 mm) (P < .001). The median length of the operation was 25 minutes. A follow-up interview revealed that there was no hernia recurrence with a median follow-up time of 20 months (range, 12-29 months). No postoperative complications were reported by the parents. As for the parents' satisfaction with wound cosmesis, 93% of them rated it as good or excellent. CONCLUSIONS: Inguinal hernia repair with the SSEM through a minimal skin incision is technically feasible, with very satisfactory surgical and cosmetic results. As it has the potential to be a standard method for inguinal hernia repair in children, a prospective study to confirm the safety of the procedure should be carried out.

Visceral coverage with absorbable mesh followed by split-thickness skin graft in the treatment of ruptured giant omphalocele.

We report a case of ruptured giant omphalocele in whom herniated organs were successfully covered by an absorbable mesh and a subsequent skin graft. A 2,200 g male baby was born at 35 weeks of gestation. An abdominal wall abnormality was detected by prenatal ultrasound at 21 weeks of gestation. At birth, the entire liver, stomach, and small and large bowel had herniated from the defect of the abdominal wall. The thorax and abdomen were highly underdeveloped, and attempts to reduce the organs into the abdomen were unsuccessful due to the extremely small abdominal cavity and associated pulmonary hypoplasia. To protect the herniated organs and prevent abdominal infections, the organs were covered by a polyglycan mesh and subsequently a meshed split-thickness skin graft. Ten weeks later, it was confirmed that the organs were completely covered by epithelialized tissue. However, the patient suffered from frequent respiratory infections and finally died of respiratory insufficiency. Based on the experience of the patient, we conclude that coverage of the herniated organs with an absorbable mesh and a skin graft is a recommendable treatment in ruptured giant omphalocele.