Two-Stage Thoracoscopic Repair of Long-Gap Esophageal Atresia Using Internal Traction Is Safe and Feasible.

BACKGROUND: The treatment of long-gap esophageal atresia remains an issue for pediatric surgeons. Many techniques for treating long-gap esophageal atresia have been proposed, but the optimal method has not been established. The thoracoscopic esophageal elongation technique has recently been developed. We previously reported a case in which two-stage thoracoscopic repair was performed using internal esophageal traction without esophageal tearing, and we retrospectively reviewed the outcomes of this procedure in this study. METHODS: Five patients underwent thoracoscopic treatment involving internal esophageal traction for esophageal atresia involving a long gap or vascular ring over a 5-year period. RESULTS: Between November 2010 and November 2015, 5 patients were treated with thoracoscopic traction. All of these patients successfully underwent thoracoscopic-delayed primary anastomosis. Conversion to open thoracotomy was not required in any case. The postoperative complications experienced by the patients included minor anastomotic leakage in 2 cases, anastomotic stenosis in 1 case, gastroesophageal reflux (GER) in 4 cases, and a hiatal hernia in 1 case. None of the patients died. CONCLUSIONS: Two-stage thoracoscopic repair for esophageal atresia involving a long gap or vascular ring is a safe and feasible procedure; however, we must develop methods for treating minor anastomotic complications and GER due to esophageal traction in future.

Left thoracoscopic two-stage repair of tracheoesophageal fistula with a right aortic arch and a vascular ring.

A right aortic arch (RAA) is found in 5% of neonates with tracheoesophageal fistulae (TEF) and may be associated with vascular rings. Oesophageal repairs for TEF with an RAA via the right chest often pose surgical difficulties. We report for the first time in the world a successful two-stage repair by left-sided thoracoscope for TEF with an RAA and a vascular ring. We switched from right to left thoracoscopy after finding an RAA. A proximal oesophageal pouch was hemmed into the vascular ring; therefore, we selected a two-stage repair. The TEF was resected and simple internal traction was placed into the oesophagus at the first stage. Detailed examination showed the patent ductus arteriosus (PDA) completing a vascular ring. The subsequent primary oesophago-oesophagostomy and dissection of PDA was performed by left-sided thoracoscope. Therefore, left thoracoscopic repair is safe and feasible for treating TEF with an RAA and a vascular ring.

Steroid pulse therapy prevents restenosis following balloon dilatation for esophageal stricture.

PURPOSE: This study aimed to evaluate the effectiveness of intravenous steroid pulse therapy following balloon dilatation for esophageal stenosis and stricture in children. METHODS: The study enrolled six children, including three with congenital esophageal stenosis and three with anastomotic strictures after surgery for esophageal atresia, all of whom were treated by balloon dilatation combined with high-dose intravenous methylprednisolone pulse therapy. Methylprednisolone was injected intravenously at a dose of 20 mg/kg/day for 2 days, starting from the day of dilatation, followed by 10 mg/kg/day for 2 days, for a total of 4 days. RESULTS: Esophageal stricture recurred in all three patients with congenital esophageal stenosis despite repeated balloon dilatation without methylprednisolone. However, the symptoms of dysphagia improved and did not recur after systemic steroid pulse therapy following balloon dilatation. Symptoms also resolved in all three patients with anastomotic strictures following balloon dilatation with systemic steroid pulse therapy. All six patients remained asymptomatic after 6-21 months follow-up, with no complications. CONCLUSION: Intravenous methylprednisolone pulse therapy following balloon dilatation is safe and effective for the treatment of esophageal stenosis and strictures in children.

A new modification of laparoscopic percutaneous extraperitoneal closure procedure for repairing pediatric femoral hernias involving a special needle and a wire loop.

Femoral hernias are relatively rare in children, and more than half of pediatric femoral hernias are misdiagnosed. A 3-year-old boy was treated for an indirect inguinal hernia at the age of 2, but he exhibited an inguinal bulge one month after the operation. He underwent laparoscopy, and a right femoral hernia was detected. The femoral hernia was laparoscopically repaired via two small incisions: a 1.0-cm umbilical incision for a 3-mm 30° laparoscope and 3-mm grasping forceps and a 5-mm right lateral incision for 3-mm grasping forceps. After the hernia sac had been reflected into the abdominal cavity and resected, the iliopubic tract was sutured to Cooper's ligament using a laparoscopic percutaneous extracorporeal closure (LPEC) needle and 2-0 non-absorbable sutures. Laparoscopy enables the accurate diagnosis of rare and often missed pediatric femoral hernias. Our laparoscopic technique for treating femoral hernias is easy and effective. Although these early results are encouraging, more cases involving longer follow-up periods should be accumulated to confirm the efficacy of our technique.

A New Era of Laparoscopic Revision of Kasai Portoenterostomy for the Treatment of Biliary Atresia.

PURPOSE: Kasai portoenterostomy is the standard therapy for biliary atresia (BA). If Kasai is unsuccessful, there is controversy over whether revision of Kasai restores adequate biliary drainage. Although there are several reports of laparoscopic Kasai (Lap-Kasai), none has described laparoscopic revision (Lap-revision). The purposes of this study were to evaluate the feasibility and efficacy of Lap-revision. METHODS: 65 patients underwent open Kasai between November 2001 and November 2013, and 12 patients underwent Lap-Kasai between December 2013 to January 2015. The indications for revision included bile flow cessation and recurrent cholangitis. Clinical data were compared between open and laparoscopic revisions of Kasai. RESULTS: Open revision of Kasai was performed in 20 patients after open Kasai, and Lap-revision was performed in 4 patients after Lap-Kasai. Lap-revision was completed without conversion or major complication in any patient. The bilirubin level was normalized by Lap-revision in all four patients, and three of them were alive with their native liver. Open and laparoscopic revisions of Kasai were comparable in terms of the operation time, blood loss, and surgical outcomes. CONCLUSION: Lap-revision is a feasible and effective method for the treatment of BA and might herald a new era for the treatment of this disease.

Antenatal magnetic resonance imaging is useful in providing predictive values for surgical procedures in abdominal wall defects.

BACKGROUND: Antenatal magnetic resonance imaging (MRI) is useful for the diagnosis of abdominal wall defects. Its predictive value concerning the possibility of primary closure of the abdominal wall, however, has so far not been reported. METHODS: Between August 2001 and November 2004, antenatal MRI was performed on 9 patients with abdominal wall defects in whom surgical repair was performed immediately after birth. Areas of the abdominal cavity and exteriorized viscera were manually traced from both sagittal and axial MR images, and the data were further transmitted to a Workstation for MRI Volumetry (Advantage Windows 4.1, General Electric Medical Systems, Milwaukee, Wis). We examined the exteriorized ratio (ER), which is calculated by dividing the absolute volume of the abdominal cavity by that of the exteriorized viscera, and evaluated the predictive value by a retrospective comparison with surgical procedure. RESULTS: In the primary closure group (n = 5), mean values of ER were 0.33 +/- 0.31 from axial and 0.45 +/- 0.31 from sagittal MR images. In contrast, in the staged closure group (n = 4), mean values of ER were 1.39 +/- 0.40 from axial and 1.34 +/- 0.42 from sagittal MR images. There was a significant difference (P < .05) between the 2 groups for both sets of images. The ER obtained from antenatal MRI correlated well with surgical procedure. CONCLUSIONS: The ER might be useful for antenatal counseling, planning for delivery, and prediction of the most likely surgical procedure.

Intrapancreatic axonal hyperbranching of dorsal root ganglia neurons in chronic pancreatitis model rats and its relation to pancreatic pain.

OBJECTIVES: Increase in number of intrapancreatic nerve bundles has been implicated in the generation of persistent pain in chronic pancreatitis. To examine the origin of these nerve fibers and the mechanisms linking neural morphological change to pain generation, we used neuronal tracing techniques in combination with immunohistochemistry in spontaneous chronic pancreatitis in the Wistar Bonn/Kobori (WBN/Kob) rats. METHODS: For retrograde tracing, horseradish peroxidase was injected into the pancreas, and labeled neurons in the sensory ganglia were counted. For anterograde tracing, biotinylated dextran amine was injected into the dorsal root ganglia (DRGs), and labeled intrapancreatic sensory fibers were histochemically assessed. For assessment of pain generation, we evaluated c-Fos-positive neurons in the spinal dorsal horn and behavioral changes of the animals. RESULTS: In WBN/Kob rats, the numbers of horseradish peroxidase-labeled neurons were decreased in the DRGs, and the numbers of biotinylated dextran amine-labeled intrapancreatic nerve fibers and terminals were increased. Biotinylated dextran amine-labeled nerve fibers contained growth-associated protein 43. The number of c-Fos-positive neurons in the dorsal horn was also increased and was correlated with intrapancreatic growth-associated protein 43 immunoreactivity. Grooming behavior was reduced in WBN/Kob rats, and this reduction was facilitated by exocrine stimulation. CONCLUSIONS: Axonal branching in DRG neurons innervating the pancreas increases in WBN/Kob rats, and these morphological changes are likely involved in pain generation in chronic pancreatitis.

Effect of perductal paclitaxel exposure on the development of MNU-induced mammary carcinoma in female S-D rats.

BACKGROUND: Breast carcinoma and precancer are thought to start in the lining of the milk duct or lobule. METHODS: At 5weeks of age, rats received a intraperitoneal (ip) injection of MNU for carcinogenesis. After mammary tumors were identified macroscopically using fiberscope, the rats were treated with perductal (pd) or ip injection of paclitaxel tri-weekly. At 36 weeks after MNU injection, tumor burden (No. of >1cm palpable mammary tumors/rat), total number of mammary carcinoma, apoptosis (AI), and microvessel density (MVD) were measured. RESULTS: The administration of paclitaxel through the duct did not produce any toxic side effect. The tumor burden and total number of mammary carcinoma in the pd paclitaxel-treated group were significantly reduced compared to those seen in the ip paclitaxel-treated group. In addition, in the pd paclitaxel-treated group, AI was also increased and MVD was decreased, compared to those in the ip paclitaxel-treated group. CONCLUSION: Local administration of paclitaxel may be useful for treatment of breast cancer.

Structural development of PGP9.5-immunopositive myenteric plexus in embryonic rats.

To investigate relationships between changes in the 3-dimensional structure of the myenteric plexus and the time at which functional movement of intestine begins in mammalian embryos, whole mounts of embryonic rat intestine were examined under confocal laser scanning microscopy on spacer-equipped glass slides after immunostaining with antiprotein gene product 9.5 antibody. At embryonic day 12.5, very few nerve cells were scattered throughout the small intestine, but no immunostained structures were apparent on the anal side of the large intestine. At embryonic day 13.5, immunostained fibers appeared on the oral side of the large intestine. Nerve cells and associated fiber bundles formed neuronal networks with large meshes in both intestines. Marked increases in number of nerve fibers and decreases in mesh size were seen in the small intestine between embryonic days 13.5 and 15.5. Similar changes were found in the large intestine between embryonic days 13.5 and 16.5. After embryonic day 16.5, nerve cells were arranged parallel to circular muscle fibers, and networks formed by cell fibers elongated until the neonatal period in both intestines. Meconium passed through the large intestine from embryonic day 17.5. Thin fiber bundles extended from the ganglion to the inner side of the myenteric layer, parallel (and occasionally extending) to the circular muscle fibers. Formation of nerve fiber networks and arrangement of nerve cells parallel to circular muscle fibers probably relate to movement coordination for inner circular muscle fibers in the intestinal wall, and development of this neural network may be important for acquiring intestinal movements before birth.

Congenital biliary dilatation in dizygotic twins.

Congenital biliary dilatation (CBD) of different types was recently noted in dizygotic twins. Our cases suggest the possibility of hereditary involvement in CBD. On the other hand, CBD discordance in six sets of monozygotic twins has been reported, which would suggest that the occurrence of CBD is not compatible with single gene control, although environmental factors are plausible. To evaluate the genetic factors that may be implicated in CBD, it would be necessary to accumulate more familial cases and examine further studies on inheritance.

Thoracoscopic diaphragmatic procedures under artificial pneumothorax.

Diaphragmatic plication is technically simple using a conventional operative technique, but it requires a large skin incision and rib injury. We present an alternative technique for thoracoscopic plication of the diaphragm and evaluate the advantages of the procedure. Six patients (five with diaphragmatic eventration and one with diaphragmatic hernia with a sac) ranging in age from 8 to 20 months were treated by this method. Three of the six cases were right-sided, and three were left-sided. The operation was performed under artificial pneumothorax using carbon dioxide gas at 4 mmHg. Three trocars for laparoscopy were inserted at the 4th and 5th intercostal spaces. An adequate operative view was obtained by pressing the diaphragm throughout the operation. The eventrated diaphragm was plicated with several rows of nonabsorbable sutures in the anterolateral-to-posterolateral direction to prevent injury to the main phrenic nerve. A tight diaphragm was confirmed by decompressing the artificial pneumothorax. The technique was successfully performed in all cases, and the patients' postoperative courses were uneventful. During the operation, the hemodynamic effects of carbon dioxide gas at 4 mmHg were minimal. Over a mean follow-up period of 3.1 years (range, 1-6 years), no recurrence of diaphragmatic eventration was seen. Judging from the satisfactory postoperative course, this procedure is suitable for children with all forms of diaphragmatic eventration.