[Preoperative Virtual Reality Simulation Regarding the Appropriate Port Location for Thoracoscopic Surgery for the Mediastinal or Chest Wall Lesions].

In thoracoscopic surgery for mediastinal or chest wall lesions the suitable position of ports( trocars) are required depending on the position of a target lesion in a particular patient. We have therefore developed a virtual reality (VR) simulation system using the specific data of each individual patient. The model data generation system, PASS-GEN, is customized for thoracic surgery. The chest wall and organs around the tumor are extracted from DICOM image data of computed tomography (CT) scan, and three-dimensional (3D) virtual images are constructed. Rehearsal of ports insertion is carried out by locating the scope and the forceps anywhere on the chest wall on PC monitor. The constructed VR images clearly show three dimensional relationships between the target and surrounding structures. This system also simulates circumstances where on the chest wall a thoracoscope and tools should be inserted for the better view and more comfortable manipulation. Particularly in mediastinal or chest wall surgery VR simulation is more practical because those structures would be less transformed during operation.

Safety and Feasibility of Laparoscopic Resection of Neuroblastoma Without Image-Defined Risk Factors Performed by Pediatric Surgical Trainees: A Multicenter Comparison Study.

Introduction: Laparoscopic resection has gradually been adopted for neuroblastoma patients; however, some authors reported that, due to its technically demanding procedures, this operation should be performed only by highly experienced surgeons. The aim of this study was to evaluate the safety and feasibility of laparoscopic resection of abdominal neuroblastoma by pediatric surgical trainees. Subjects and Methods: In this multicenter, retrospective study, including 18 children with abdominal neuroblastoma indicated for 19 laparoscopic resections (1 with bilateral neuroblastomas) from 1999 to 2018, the clinical data were retrospectively reviewed and compared between trainee and attending surgeons. Results: None of the cases had image-defined risk factors (IDRFs) at surgery. All patients successfully underwent complete laparoscopic resection without blood transfusion, open conversion, or intraoperative or postoperative complications. Of the 19 cases, 6 were performed by pediatric surgical trainees under the guidance of attending surgeons, and 13 were performed by attending surgeons. With comparable tumor, largest diameter, operative time, and bleeding amount were not significantly different between the two groups. In the trainee surgeon group, one local recurrence occurred at a secondary resection site in the bilateral neuroblastoma patient with Stage L2. Conclusions: Laparoscopic resection of neuroblastoma could be safe and feasible when limited to absent IDRFs at surgery by pediatric surgical trainees under the guidance of experienced attending surgeons, as well as by attending surgeons.

Laparoscopic retroperitoneal splenopexy for wandering spleen: A novel technique using a three-incision retroperitoneal pouch.

INTRODUCTION: Wandering spleen is a rare condition for which splenopexy is indicated to prevent splenic torsion. We present a novel laparoscopic splenopexy technique for wandering spleen based on creation of a three-incision retroperitoneal pouch. MATERIALS AND SURGICAL TECHNIQUE: A 12-year-old male patient with abdominal distention and vomiting was transferred to our institution. Contrast-enhanced CT revealed a swollen wandering spleen with associated gastric volvulus, and the patient underwent laparoscopic surgery. A 5-mm camera port was inserted through an umbilical incision with two additional ports, one in the right upper abdomen and one in the left flank. Normal saline was injected into the retroperitoneal space from the left flank with a 23-G needle to create a retroperitoneal pouch. Three ventrodorsal peritoneal incisions were created at the same site in the peritoneum. The swollen spleen was inserted into the retroperitoneal pouch from the central incision, and the upper and lower poles of the spleen were exposed to the abdominal cavity from the cranial and caudal incisions to prevent splenic torsion. Finally, anterior gastropexy was performed. The postoperative period was uneventful. The patient was discharged on postoperative day 11 without complaints. As of 10 months after surgery, the patient had no recurrences of splenic torsion or gastric volvulus. DISCUSSION: In the present method, the retroperitoneal pouch was created without difficulty by injection of normal saline. Even in a patient with a swollen spleen, this novel method could prevent splenic torsion without using artificial materials or extensively dissecting the retroperitoneal space.

Development and validation of risk models for mortality and morbidity in 12 major pediatric surgical procedures: A study from the National Clinical Database-Pediatric of Japan.

PURPOSE: To establish and validate risk models of mortality and morbidity associated with 12 major pediatric surgical procedures using the National Clinical Database-Pediatric (NCD-P) data. METHODS: We used the NCD-P data for the development and validation datasets. By using multivariate logistic regression to analyze the development dataset, we created a prediction model for 30-day mortality and morbidity in 12 major pediatric surgical procedures, including tracheoplasty, pneumonectomy, fundoplication, total/subtotal excision of malignant tumor, and surgeries for Hirschsprung disease, anorectal malformation, biliary atresia, choledocal cyst, midgut volvulus, funnel chest, gastrointestinal perforation, and intestinal obstruction. We selected variables that were almost identical to those used in the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P). The primary outcomes were 30-day mortality and composite morbidity. We assessed the obtained models using the C-indices of the development and validation datasets. RESULTS: Overall, 10 and 21 variables were identified for mortality and morbidity, respectively. C-indices of mortality were 0.940 and 0.924 in the development and validation datasets, respectively. C-indices of morbidity were 0.832 and 0.830 in the development and validation datasets, respectively. CONCLUSIONS: Based on the NCD-P data, we developed satisfactory risk models for mortality and morbidity prediction in major pediatric surgeries. LEVEL OF EVIDENCE: Level I (Prognosis Study).

Ethanol lock therapy in pediatric patients: A multicenter prospective study.

BACKGROUND: Ethanol lock therapy (ELT) has been performed for the purpose of preserving central venous catheters (CVC) in central venous catheter-related blood stream infection (CRBSI), but evidence for its effectiveness is not established. We conducted a multicenter, prospective study on the ELT protocol to ascertain its safety and effectiveness against CRBSI. METHODS: The subjects were patients aged over 1 year with potential for developing CRBSI who had long-term indwelling silicone CVCs. After culturing the catheterized blood, a 70% ethanol lock was performed daily for 2-4 h for 7 days. The effectiveness rate of ELT for single and multiple courses, the presence or absence of relapse of CRBSI within 4 weeks of treatment, and whether the CVC could be salvaged after 4 weeks were examined. RESULTS: From September 2014 to August 2018, 49 cases from six hospitals were enrolled in the study. Catheter blockage was seen in one case and the CVC was removed. A single course of ELT was effective in episodes 88% (42/48). In the remaining three episodes that failed after a single course of ELT, a second ELT was performed; however, all were ineffective. In episodes 93% (40/42), no CRBSI relapse was seen up to 4 weeks after the end of treatment. In episodes 84% (41/49), the catheter could be preserved for 4 weeks or more after the end of treatment. Facial flushing was seen in two cases as an adverse event; however, this was transient and soon disappeared. CONCLUSION: ELT is effective for 88% of CRBSI and 84% of catheters can be salvaged; therefore, this protocol is considered useful. TRIAL REGISTRATION: UMIN000013677.

Treatment guidelines for persistent cloaca, cloacal exstrophy, and Mayer-Rokitansky-Küster-Häuser syndrome for the appropriate transitional care of patients.

We developed treatment guidelines (TGs) for appropriate transitional care of the genitourinary system in patients with persistent cloaca (PC), cloacal exstrophy (CE), or Mayer-Rokitansky-Küster-Häuser syndrome (MRKH). These TGs are in accordance with the Medical Information Network Distribution Service (Minds), published in 2014 in Japan. Clinical questions (CQs) concerning treatment outcomes of the genitourinary system, pregnancy and delivery, and quality of life in adulthood were prepared as six themes for PC and CE and five themes for MRKH. We were able to publish statements on chronic renal dysfunction, hydrometrocolpos, and pregnancy, based on four CQs about PC, four about CE, and two about MRKH, respectively. However, due to the paucity of proper manuscripts, we were unable to make conclusions about the correct timing and method of vaginoplasty for patients with PC, CE, and MRKH or the usefulness of early bladder closure for patients with CE. These TGs may help clarify the current treatments for PC, CE, and MRKH in childhood, which have been carried out on an institutional basis. To improve clinical outcomes, systematic clinical trials revealing comprehensive clinical data of the urinary and reproductive systems, especially the length of the common channel in PC, are essential.

Shwachman-Diamond syndrome: Nationwide survey and systematic review in Japan.

BACKGROUND: Shwachman-Diamond syndrome (SDS) is a rare multisystem disorder associated with exocrine pancreatic insufficiency. The present study reports the results of a nationwide survey and a systematic review on SDS to develop consensus guidelines for intractable diarrhea including SDS. METHODS: Questionnaires were sent to 616 departments of pediatrics or of pediatric surgery in Japan in a nationwide survey. A second questionnaire was sent to doctors who had treated SDS patients and included questions on clinical information. Additionally, a systematic review was performed using digital literature databases to assess the influence of medical (i.e. non-surgical) treatment on SDS prognosis. RESULTS: Answers were received from 529 institutions (85.9%), which included information on 24 patients with SDS (median age, 10.4 years; male, n = 15) treated from January 2005 to December 2014. Although 75% of patients received pancreatic enzyme replacement therapy, there was no significant association between treatment and prognosis. Systematic review identified one clinical practice guideline, two case series, eight case reports and 26 reviews. Patient information from those studies was insufficient for meta-analysis. CONCLUSIONS: The rarity of SDS makes it difficult to establish evidence-based treatment for SDS. According to the limited information from patients and published reports, medical treatment for malabsorption due to SDS should be performed to improve fat absorption and stool condition, but it is not clear whether this treatment improves the prognosis of malabsorption.

Learning curve for the thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.

AIM: Thoracoscopic repair (TR) of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains a considerable challenge, even for the most experienced pediatric surgeons. The aim of this study is to report the outcomes of our experience with TR of EA/TEF and to determine the learning curve for this procedure. METHODS: Eleven consecutive cases that had undergone TR of EA/TEF at our institutes were included in this study. The medical charts were reviewed retrospectively. To determine the learning curve for TR of EA/TEF, a logarithmic curve-fitting analysis was performed. The data were expressed as medians with ranges. RESULTS: The median age and birth weight were 1 day (range, 1-3 days) and 2.8 kg (range, 2.5-3.7 kg), respectively. TR was completed in all cases without any complications. The median operative time was 230 min (range, 164-383 min). There were no cases of anastomotic leakage. One patient with a long gap required repeated balloon dilatation for refractory anastomotic stricture. No mortality or recurrence of tracheoesophageal fistula occurred. The operative time was significantly longer in patients with a long gap (>20 mm) than in those with a shorter gap. Once the three cases with a long gap had been excluded, the operative time decreased as the number of treated cases increased. The relationship between the operative time and case number fit a logarithmic function curve well (operative time in minutes = 300 - 62 × log (case number), R2  = 0.8359, P = 0.0015). CONCLUSIONS: Our results suggest that TR of EA/TEF is a safe procedure. It has a considerable learning curve, but requires advanced endoscopic surgical skills.

Clinical practice guidelines for congenital hyperinsulinism.

Congenital hyperinsulinism is a rare condition, and following recent advances in diagnosis and treatment, it was considered necessary to formulate evidence-based clinical practice guidelines reflecting the most recent progress, to guide the practice of neonatologists, pediatric endocrinologists, general pediatricians, and pediatric surgeons. These guidelines cover a range of aspects, including general features of congenital hyperinsulinism, diagnostic criteria and tools for diagnosis, first- and second-line medical treatment, criteria for and details of surgical treatment, and future perspectives. These guidelines were generated as a collaborative effort between The Japanese Society for Pediatric Endocrinology and The Japanese Society of Pediatric Surgeons, and followed the official procedures of guideline generation to identify important clinical questions, perform a systematic literature review (April 2016), assess the evidence level of each paper, formulate the guidelines, and obtain public comments.

Coronary Sinus Orifice Atresia After the Fontan Completion: Unique Repair Technique.

We report a successful unroofing of the coronary sinus via a unique technique. Our patient was diagnosed with single ventricle morphology. Pulmonary artery banding and bidirectional cavopulmonary shunt were performed at 1 and 6 months old, respectively. Ordinary univentricular repair strategy was performed; extracardiac total cavopulmonary connection was achieved at 18 months old. Catheterization performed 1 year after the Fontan procedure revealed the coronary sinus orifice atresia, diffuse coronary artery stenosis, and sinusoid formation of the coronary system. We present a new technique using a small bronchial fiberscope to identify a coronary sinus buried in the atrial wall.

A novel approach to neonatal abdominal surgery via a circular incision around the umbilical cord.

We present a new, scarless, circular incisional approach around the umbilical cord for neonates with intestinal atresia. This novel approach achieves truly woundless surgery. It is simple, safe, and can be used for an intestinal surgical treatment in neonates.

Laparoscopic repair of sliding inguinal hernia in female children.

PURPOSE: To evaluate the safety and feasibility of laparoscopic repair of sliding inguinal hernia in female children. METHODS: Laparoscopic percutaneous extraperitoneal closure (LPEC) was performed in 482 female inguinal hernia children between 2006 and 2015. Fourteen of these patients were associated with sliding inguinal hernia, and these 14 patients were enrolled and reviewed retrospectively. RESULTS: The mean age and the body weight at the operation was 9.6 months and 7.8 kg. Seven patients required the reduction of the ovary under general anesthesia. Laparoscopy, however, revealed that five patients had severe sliding of fallopian tube into the inguinal canal. One of these five patients received a simple LPEC, but developed the recurrence due to the low ligation of the hernia sac, and needed the second hernia repair under inguinal approach. Other four patients with fallopian tube sliding required the dissection of the fallopian tube and peritoneal repair, or the conversion to inguinal approach; therefore they had longer surgical time compared to those without fallopian tube sliding. CONCLUSION: LPEC is safe and feasible for the sliding inguinal hernia repair except the cases with fallopian tube sliding. Patients with fallopian tube sliding required additional procedure or conversion to inguinal approach.

Anterior mediastinal tracheostomy with a median mandibular splitting approach in a Larsen syndrome patient with posterior cervical arthrodesis.

Larsen syndrome is a rare congenital connective tissue disorder characterized by multiple joint dislocations. A novel anterior mediastinal tracheostomy with a median mandibular splitting approach is presented for the treatment of airway obstruction in a Larsen syndrome patient with posterior cervical arthrodesis.

Clinical application of indocyanine green (ICG) fluorescent imaging of hepatoblastoma.

BACKGROUND/PURPOSE: Although the usefulness of intraoperative indocyanine green (ICG) fluorescent imaging for the resection of hepatocellular carcinoma has been reported, its usefulness for the resection of hepatoblastoma remains unclear. This study clarifies the feasibility of intraoperative ICG fluorescent imaging for the resection of hepatoblastoma. METHODS: In three hepatoblastoma patients, a primary tumor, recurrent tumor, and lung metastatic lesions were intraoperatively examined using a near-infrared fluorescence imaging system after the preoperative administration of ICG. RESULTS: ICG fluorescent imaging was useful for the surgical navigation in hepatoblastoma patients. In the first case, the primary hepatoblastoma exhibited intense fluorescence during right hepatectomy, but no fluorescence was detected in the residual liver. In the second case, a recurrent tumor exhibited fluorescence between the residual liver and diaphragm. A complete resection of the residual liver, with a partial resection of the diaphragm, followed by liver transplantation was performed. In the third case with multiple lung metastases, each metastatic lesion showed positive fluorescence, and all were completely resected. These fluorescence-positive lesions were pathologically proven to be viable hepatoblastoma cells. CONCLUSION: Intraoperative ICG fluorescence imaging for patients with hepatoblastoma was feasible and useful for identifying small viable lesions and confirming that no remnant tumor remained after resection.

Efficacy and safety of strong acid electrolyzed water for peritoneal lavage to prevent surgical site infection in patients with perforated appendicitis.

PURPOSE: Our previous experimental study of perforated peritonitis in rats proved that peritoneal lavage with strong acid electrolyzed water (SAEW) has no adverse effects, reduces the bacteria count in the ascitic fluid more effectively than saline, and increases the survival rate significantly. Thus, we conducted a randomized controlled study, applying SAEW in the treatment of perforated appendicitis in children. METHODS: Forty-four patients, aged 3-14 years, were randomly divided into two groups: Group S (n = 20), in which the peritoneal cavity was lavaged with 100 ml/kg saline and the wound was washed out with 200 ml saline; and Group E (n = 24), in which the peritoneal cavity was lavaged with 100 ml/kg SAEW and the wound was washed out with 200 ml SAEW. RESULTS: No adverse effect of SAEW was observed in Group E. There was no difference in the bacterial evanescence ratio of ascitic fluid after lavage between Groups S and E (11.1 and 15.8%, respectively). A residual abscess developed in one patient from each group (5.0 and 4.2%, respectively). The incidence of surgical site infection (SSI) was significantly lower in Group E than in Group S (0 and 20%, respectively; P < 0.05). There was no difference in the duration of pyrexia, positive C-reactive protein, leukocytosis, or hospital stay between the groups. CONCLUSION: Peritoneal lavage and wound washing with SAEW have no adverse effects and are effective for preventing SSI.

Hybrid surgical repair of complete tubular colonic duplication associated with anovestibular and anocutaneous fistulas.

Complete tubular colonic duplication is a rare and complex anomaly. We present a new technique consisting of anterior sagittal anorectoplasty and fenestration of the duplicated colon using a hybrid method, involving single-incisional laparoscope-assisted and endoscopic procedures, for a case of complete tubular colonic duplication associated with anovestibular and anocutaneous fistulas.

Care of children in a natural disaster: lessons learned from the Great East Japan earthquake and tsunami.

The Great East Japan earthquake was one of the most devastating natural disasters ever to hit Japan. We present features of the disaster and the radioactive accident in Fukushima. About 19,000 are dead or remain missing mainly due to the tsunami, but children accounted for only 6.5% of the deaths. The Japanese Society of Pediatric Surgeons set up the Committee of Aid for Disaster, and collaborated with the Japanese Society of Emergency Pediatrics to share information and provide pediatric medical care in the disaster area. Based on the lessons learned from the experiences, the role of pediatric surgeons and physicians in natural disasters is discussed.

Single-site laparoscopic herniorrhaphy using needle instruments for inguinal hernias in children: a novel technique.

We describe our new technique for laparoscopic herniorrhaphy with subumbilical single-site access to treat inguinal hernias in children. First, we inserted a transparent 3-mm trocar and a 2-mm minitrocar at the umbilicus. We then inserted a 3-mm 45° camera through the 3-mm trocar and needle-grasping forceps through the 2-mm trocar. We closed the hernia defect by using a 19-gauge hooked injection needle with a nonabsorbable suture. We treated 11 consecutive female children with inguinal hernia using this operation. The mean operating time was 26.7 min (range 21-36 min) and the procedure was technically successful, without the need for additional trocars, in all 11 patients. There were no intraoperative complications and all the patients were discharged on the same day after the surgery. Single-site laparoscopic herniorrhaphy using needle instruments is feasible and seems to be safe. Further studies are required to determine whether this approach would benefit patient compared with standard laparoscopic herniorrhaphy.

Effect of electrolyzed strong acid water on peritoneal irrigation of experimental perforated peritonitis.

PURPOSE: Electrolyzed strong acid water (ESAW) is generated by the electrolysis of a weak sodium chloride solution. Although ESAW is known to have a strong bactericidal activity and to be harmless to the living body, its effectiveness and safety in the treatment of perforated peritonitis has not been well established. METHODS: Male Wistar rats were used for the study. Three hours after cecal ligation and puncture, the cecum was resected and the peritoneal cavity was irrigated with 50 ml of saline (Group S, n=12) or ESAW (Group E, n=14). The 5-day survival rate was compared between the two groups. In another pair of animals (n=10 each), bacteria in the ascitic fluid were counted at 6 and 18 h after irrigation. RESULTS: No adverse effects of ESAW were observed in the experimental group. The 5-day survival rate was 25% (3/12) and 85.7% (12/14) in Groups S and E, respectively (P < 0.01). The bacterial count at 18 h after the irrigation in Groups S and E was (5.0 +/- 2.5) x 10(5)/ml and (2.2 +/- 2.0) x 10(4)/ml, respectively (P < 0.0001). CONCLUSION: Peritoneal lavage with ESAW had no adverse effect, and achieved more effective decontamination than saline for perforated peritonitis. Therefore, the results of this study are considered to warrant and support the clinical application of ESAW.