The Comparison of Postoperative Umbilical Port Site-Related Complications Between Transumbilical and Periumbilical Incision After Laparoscopic Surgery in Children.

Introduction: No studies have directly compared postoperative umbilical port site (UPS)-related complications between transumbilical and periumbilical incisions (TUI and PUI) after laparoscopic surgery in children. Patients and Methods: We conducted a retrospective review of 324 children of ≤15 years of age who underwent laparoscopic repair (LR) for inguinal hernia, via either a TUI or PUI, between 2010 and 2020. UPS-related complications, such as wound infection and umbilical deformity, were compared between TUI and PUI. We also investigated the risk factors for the development of UPS-related complications after LR. Results: TUIs and PUIs were used for 228 and 96 children, respectively. The incidence rates of postoperative wound infection and umbilical deformity in the PUI group were higher in comparison to the TUI group; although not to a statistically significant extent (7.3% versus 5.3%, P = .451, 6.3% versus 4.8%, P = .593). One case of incisional hernia at the UPS was seen in the TUI group. In the univariate analysis, sex, age, weight for age Z-score, nutrition status, insertion and closure time, total operative time, American Society of Anesthesiologists score, blood loss, and comorbidities were not significantly associated with the development of UPS-related complications after LR. Conclusion: The incidence of UPS-related complications in TUI and PUI was not significantly different. Due to the low incidence of UPS-related complications, it was difficult to draw conclusions regarding contributing factors; however, meticulous care should be taken to avoid UPS-related complications when closing the UPS (Ethical approval No. 2019-24).

Risks and benefits of pediatric inguinal hernia repair: Conventional open repair vs laparoscopic percutaneous extraperitoneal closure.

INTRODUCTION: Considerable debate exists regarding the benefits of laparoscopic percutaneous extraperitoneal closure (LPEC) over conventional open repair (OR). We assessed the outcomes and feasibility of LPEC compared to OR for pediatric inguinal hernia (IH). METHODS: We retrospectively analyzed 570 children who underwent LPEC or OR. Parents decided the operative method after obtaining informed consent. Patient characteristics, operative time, complications and contralateral metachronous IH (CMIH) were compared between the groups. RESULTS: A total of 329 children underwent LPEC and 241 underwent OR. There was no significant difference in the incidence of recurrence or testicular ascent between the LPEC and OR groups (0.3% vs 0.4%, P = 0.825, 0.3% vs 0.8%, P = 0.391, respectively). No testicular atrophy was recognized in either group. One patient with postoperative chronic inguinal pain was recognized in each group. There was no surgical site infection (SSI) in the OR group; however, the LPEC group more frequently demonstrated umbilical port site (UPS)-related complications, such as incisional hernia, minor deformity, granuloma formation, cellulitis and superficial SSI. Ten (4.1%) developed CMIH in OR; in contrast, no case of CMIH was experienced after LPEC (P < 0.001). CONCLUSION: In conclusion, both LPEC and OR are feasible in the management of pediatric IH, because of their high success rates and low risk of complications. LPEC could be the superior procedure with respect to the prevention of CMIH. However, to maximize the merits of LPEC over OR, it is important to reduce UPS-related complications in LPEC. A longer follow-up is needed to assess male fertility in patients who receive LPEC.

Nonoperative management for umbilical hernia in infants using adhesive strapping.

BACKGROUND: The aim of this study was to evaluate the efficacy of adhesive strapping (AS) for umbilical hernia (UH) in infants. METHODS: A retrospective review of 30 mature infants without any treatment for UH between January 2006 and December 2008 and 87 infants (42 mature and 45 premature) who were treated with AS between January 2010 and December 2014 was conducted. The rate and age of closure of UH were compared between the groups and the complications and limitations of AS were evaluated. RESULTS: In the observation-only group, 24 UHs spontaneously closed at a mean age of 13.5 months, but a protruding umbilicus with redundant skin was present in three of 27 infants. Three infants had persistent UH, so a total of six infants, including the three with redundant skin and three with persistent UH, underwent surgery at the mean age of 30.0 months. In the AS group, 72 UHs were cured at a mean age of 4.3 months, which was significantly earlier than in the observation-only group (P < 0.01). Eleven infants did not continue AS because of skin irritation or discomfort. Four infants underwent repair due to persistent UH, but not for redundant skin of the umbilicus. CONCLUSIONS: Adhesive strapping is effective for promoting the early resolution of UH in infants and preventing the forming of redundant skin, which can reduce the need for surgical intervention. To achieve better results with AS, we recommend applying this technique before the UH grows large.

The outcomes of conservative management and the natural history of asymptomatic hydroceles in children.

PURPOSE: To elucidate the natural history of asymptomatic hydroceles (AHs) in children with conservative management and to discuss management strategies for AHs in children. METHODS: We retrospectively reviewed 113 children with AHs who were followed without immediate surgery. Patients were divided into four groups according to age at presentation; group 1: ≤ 1 month, group 2: 1-12 months, group 3: 12-24 months, and group 4: > 24 months. Ages at spontaneous resolution or surgery were reviewed. To assess the effect of AH on the testis, testicular size before and after conservative management was compared in 11 cases. RESULTS: In groups 1, 2, 3, and 4, spontaneous resolution occurred in 94.3%, 75.0%, 65.0%, and 33.3%, and the average time to resolution from presentation was 5, 5, 17, and 9 months, respectively. 41 patients underwent surgery at a mean age of 4.2 years. The testicular size did not differ significantly between before and after conservative management (14.4 vs. 14.5 mm, p = 0.483). CONCLUSION: About one-third of children over 2 years of age achieve spontaneous resolution. Hydroceles with conservative management may not affect the testicular size. Thus, initial conservative management before surgery is recommend for AHs in children, even over 2 years of age.

Management of inguinal hernia with prolapsed ovary in very low birthweight infants during neonatal intensive care unit hospitalisation.

AIM: Prolapsed ovary (PO) in an inguinal hernia (IH) may cause torsion and infarction; however, the management of IH with PO in very low birthweight (VLBW) infants during neonatal intensive care unit (NICU) hospitalisation remains inconsistent. METHODS: The medical records of 47 IHs in 30 VLBW infants during NICU hospitalisation between 2008 and 2017 were reviewed retrospectively. RESULTS: Of the 47 IHs, PO was diagnosed in 18 (38.3%). Post-natal age and body weight at diagnosis of IH with PO were 71 (44-172) days and 2120 (1305-2965) g, respectively. Seventeen IHs with PO underwent surgery for correction electively just before discharge from the NICU at the age and body weight of 94 (51-187) days and 2645 (2340-2945) g, respectively. Therefore, the time interval between diagnosis and surgery was 15 (7-90) days. There was no torsion of ovary before surgery and no postoperative complications, including apnoea and recurrence. CONCLUSIONS: The high incidence of IH with PO in VLBW infants during NICU hospitalisation was confirmed in this study. Under careful observation, elective IH repair just before discharge from the NICU could be one acceptable option for the management of IH with PO in VLBW infants during NICU hospitalisation to prevent torsion and infarction of ovary.

Thalidomide potentiates etoposide-induced apoptosis in murine neuroblastoma through suppression of NF-κB activation.

PURPOSE: Treatment for high-risk neuroblastoma is still challenging. The purpose of the present study was to determine whether thalidomide suppresses etoposide-induced NF-κB activation and thus potentiates apoptosis in murine neuroblastoma. METHODS: A murine neuroblastoma cell line, C1300, and A/J mice were used in this study. We evaluated NF-κB activation after using etoposide with or without thalidomide by quantitative analysis of NF-κB by ELISA and by Western blot analysis of IκB phosphorylation in vitro and in vivo. Induction of apoptosis was evaluated by Western blot analysis of the apoptotic signals caspase-3, 8, and 9 in vitro and by TUNEL assays in vivo. We also evaluated the efficacy of the combination of etoposide and thalidomide by assessing tumor growth and mouse survival in vivo. RESULTS: Etoposide activated NF-κB in C1300 cells. This activation was suppressed by thalidomide and IκB was re-upregulated. The apoptotic signals were enhanced by the combination of thalidomide and etoposide compared with etoposide alone in vitro, which was consistent with TUNEL assays. The combination of etoposide and thalidomide also slowed tumor growth and mouse survival. CONCLUSION: Thalidomide potentiates etoposide-induced apoptosis in murine neuroblastoma by suppressing NF-κB.

Paraneoplastic Syndrome of Angiomatoid Fibrous Histiocytoma May Be Caused by EWSR1-CREB1 Fusion-induced Excessive Interleukin-6 Production.

We describe a 7-year-old girl with angiomatoid fibrous histiocytoma (AFH) presenting severe inflammatory symptoms. The cytokine/chemokine profile of serum samples before and after surgery demonstrated that interleukin (IL)-6 had decreased by the greatest percentage. The AFH cells were immunopathologically positive for IL-6 and Tyr705-phosphorylation of signal transducer and activator of transcription 3. The EWSR1-CREB1 fusion gene detected in the tumor leads to continuous activation of CREB1 and IL-6 production, because the promoter region of IL-6 has a CREB binding site. Thus, IL-6 plays pivotal roles in both paraneoplastic syndrome and the oncogenesis of AFH.

Laparoscopic percutaneous extraperitoneal closure for inguinal hernia: learning curve for attending surgeons and residents.

BACKGROUND/PURPOSE: Laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia is a simple technique in which a purse-string suture made of nonabsorbable material is placed extraperitoneally around the hernia orifice by a special suture needle (Lapaherclosure™). Concerns have been raised about the extensive learning curve for both attending surgeons and residents to master this technique. This study assesses the difference in learning curves for the safe performance of LPEC by attending surgeons and residents. METHODS: A retrospective analysis was performed on the surgical charts of 409 consecutive patients (175 girls, 234 boys) who had undergone LPEC for inguinal hernia repair from December 2005 to December 2011 at Jikei University Hospital. The number of operation needed by attending surgeons and residents to reach the appropriate operation time was analyzed by the Mann-Whitney U test. RESULTS: LPEC was performed by three attending surgeons and four residents who had not previously performed LPEC. The standard operation time for LPEC by attending surgeons who have performed more than 100 LPEC cases safely is 30 min. In our study, the attending surgeons needed a mean of 12 operations (range, 10-16) to reach 30 min for LPEC. Three residents needed a mean of 31 operations (range, 27-33) to reach 30 min for LPEC. The fourth resident could not perform LPEC in 30 min or less. The difference between the number of operations needed by the attending surgeons and the residents to perform LPEC safely was statistically significant (P < 0.05). The overall incidence of contralateral patent processus vaginalis was 47.9 %. CONCLUSIONS: Our learning curve analysis showed that whereas attending surgeons needed a mean of 12 operations to perform LPEC repairs safely in 30 min or less, residents needed more than 30 operations to safely perform LPEC repairs without supervision.