Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Some congenital diaphragmatic hernias are diagnosed beyond 1 month. A late-presenting congenital diaphragmatic hernia shows a variety of clinical manifestations, and the preoperative clinical course is variable. We herein report a pediatric case of late-presenting congenital diaphragmatic hernia diagnosed as acute abdomen. CASE PRESENTATION: A 5-year-old boy was brought to our hospital because of herniation of the intestine into the left thoracic cavity, which was observed on radiography performed for abdominal pain. Enhanced computed tomography showed herniation of the small intestine and colon into the left thoracic cavity. Emergency laparoscopic surgery was performed based on the diagnosis of left diaphragmatic hernia. The entire small intestine and part of the colon herniated from the posterolateral defect of the diaphragm. We were able to retract the herniated intestine back into the abdomen but confirmed that the diaphragmatic defect and closure of the defect seemed to be technically challenging via laparoscopy; therefore, we converted the procedure to open laparotomy. The diaphragmatic defect was directly closed with interrupted sutures, and the thoracic cavity was degassed. Postoperatively, the left lung was found to be poorly expanded, but pulmonary hypoplasia was not evident in this case. CONCLUSIONS: We herein report a pediatric case of late-presenting congenital diaphragmatic hernia diagnosed as abdominal pain. Late-presenting congenital diaphragmatic hernias present with a wide variety of symptoms; therefore, it is important to be reminded of these conditions and check chest radiographs in children presenting with acute or chronic respiratory or gastrointestinal symptoms of unknown etiology.

DOI： 10.1186/s40792-024-01980-0

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PURPOSE: Ultrasound-guided supraclavicular catheterization (UGSC) of the brachiocephalic vein (BCV) for long-term tunneled central venous catheter (tCVC) insertion may be safer than the internal jugular vein approach due to its superior field of view. We examined the clinical outcomes of tCVC insertions performed by junior residents through UGSC of the BCV. PATIENTS AND METHODS: From January 2018 to December 2023, we assessed clinical outcomes and compared the experience levels of surgeons conducting tCVC insertions. Surgeons were categorized into three groups: junior residency (JR), senior residency (SR), and board-certified pediatric surgeons (BCPS). RESULTS: 177 tCVC insertions were done on 146 patients. Intraoperative complications included 6 cases of arterial puncture, 1 case of pneumothorax, 1 case of over insertion of catheter tip, and 1 case of suspected hemothorax. Distribution across groups was as follows: 28 cases (15.8%) in JR group, 92 (52.0%) in SR group, and 57 (32.2%) in BCPS group. Although the JR group exhibited longer operation times than the BCPS group, no significant differences in intraoperative complications were noted. CONCLUSION: Junior residents can safely perform UGSC for tCVC insertion. However, careful consideration of complications such as arterial or thoracic puncture is essential and case selection should be based on experience.

DOI： 10.1007/s00383-024-05773-2

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PURPOSE: Frequent post-operative cholangitis in biliary atresia (BA) affects the long-term native liver survival. This study assessed the characteristics of early cholangitis and their influence on the prognosis. METHODS: Forty-three patients with BA who underwent surgery between 2000 and 2020 were analyzed for routine inflammatory markers. Early cholangitis characteristics were compared between native liver survivor (NLS) and living donor liver transplant (LDLT) patients. RESULTS: Among the 43 patients, 30 (69.8%) experienced 130 episodes of cholangitis. In the area under the receiver operating characteristics curve (AUROC) analysis, the cutoff value of the total cholangitis episodes was 3, with an area under the AUROC curve of 0.695 (95% confidence interval 0.522-0.868). Before 3 years old, 113 episodes (86.9%) of cholangitis were observed. The white blood cell, C-reactive protein, and alanine aminotransferase values at cholangitis onset did not markedly differ between the LDLT and NLS groups. Conversely, the neutrophil-to-lymphocyte ratio in the NLS group was significantly lower than in the LDLT group (0.85 vs. 1.63, p < 0.001). CONCLUSIONS: Cholangitis in the NLS group was lymphocyte-dominant and atypical in its pathogenesis. Lymphocyte-dominant cholangitis is non-suppurative, and future research should clarify its pathogenesis to improve the treatment and prognosis of BA.

DOI： 10.1007/s00383-024-05774-1

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Language：Japanese   Publisher：(一社)日本周産期・新生児医学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: We compared the clinical features of patients with biliary atresia (BA) associated with a bleeding tendency (BT) at the time of the diagnosis with those of patients without a bleeding tendency (NBT). METHODS: The patients' background characteristics, age in days at the first visit, Kasai portoenterostomy (KPE), and postoperative course were retrospectively analyzed. RESULTS: Nine of the 93 BA patients (9.7%) showed a BT, including 7 with intracranial hemorrhaging (ICH), 1 with gastrointestinal bleeding, and 1 with a prothrombin time (PT) of 0%. The age at the first visit was 62 ± 12 days old for BT patients and 53 ± 27 days old for NBT patients (p = 0.4); the age at KPE was 77 ± 9 days old for BT patients and 65 ± 24 days old for NBT patients (p = 0.2); the time from the first visit to surgery was 13 ± 7 days for BT patients and 11 ± 10 days for NBT patients (p = 0.5); and the native liver survival rate was 56% for BT patients and 58% for NBT patients (p = 1), with no significant difference in any of the parameters. The neurological outcomes of survivors of ICH were favorable. CONCLUSIONS: Appropriate BT correction allowed early KPE even after ICH, resulting in native liver survival rates comparable to those of NBT patients without significant neurological complications.

DOI： 10.1007/s00595-023-02744-3

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BACKGROUND: Most cases of intestinal malrotation appear in neonates with bilious vomiting due to midgut volvulus, whereas in cases that develop beyond infancy, the initial symptoms vary. This study investigated the clinical features of these two populations and identified issues that should be considered in daily practice. METHODS: A retrospective chart review was conducted from January 1, 2010, to December 31, 2022. Data on patients with intestinal malrotation were collected in an anonymized fashion from five pediatric surgical hub facilities in the Southern Kyushu and Okinawa areas of Japan. RESULTS: Of the 80 subjects, 57 (71.3%) were neonates (Group N) and 23 (28.7%) were infants and schoolchildren (Group I). The frequencies of initial symptoms, such as abdominal distention (Group N: 19.3% vs. Group I: 13.0%), bilious vomiting (59.6% vs. 43.5%), and hematochezia (8.8% vs. 21.7%), were not skewed by the age of onset (p = 0.535, 0.087, and 0.141, respectively). Midgut volvulus was significantly more frequent in Group N (71.9% [41/57] vs. 34.8% [8/23]; p = 0.005), while the degree of torsion was greater in group I (median 360° [interquartile range: 180-360°] vs. 450° [360-540°]; p = 0.029). Although the bowel resection rate was equivalent (7.0% [4/57] vs. 4.3% [1/23]; p = 1.000), half of the patients in Group N presented with 180° torsion. The neonatal intestine has been highlighted as being more susceptible to ischemia than that in older children. CONCLUSIONS: The incidence of midgut volvulus is higher in neonates than in older children. Even relatively mild torsion can cause ischemic bowel changes during the neonatal period. LEVEL OF EVIDENCE: LEVEL III.

DOI： 10.1016/j.jpedsurg.2023.11.020

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

【目的】中心静脈カテーテル(CVC)は小児血液・悪性固形腫瘍患者の治療において使用される.近年,安全なCVC挿入法としてin-plane法を用いた超音波(US)ガイド下鎖骨上アプローチによる腕頭静脈穿刺CVC挿入術が報告されている.【方法】小児血液・悪性固形腫瘍患者を対象にout-of-plane法を用いて内頸静脈にトンネル型CVCを挿入した群(IJV群)とin-plane法を用いて腕頭静脈に挿入した群(BCV群)について患者背景,手術成績,合併症を後方視的に比較検討した.【結果】34名の患者に対し,計40回(IJV群:n=15,BCV群:n=25)のトンネル型CVCが挿入された.患者背景,術前血液凝固検査値は両群間に有意差はなかった.手術時間中央値(IQR)はIJV群:30分(27～33),BCV群:25.8分(22～27)であり,BCV群で有意に手術時間が短縮された(p=0.0026).術中合併症はIJV群で1例(6.7%)認め,BCV群では認めなかった.CVC維持管理中の合併症はIJV群:10例(66.7%),BCV群:17例(68%)であり,両群間で有意差は認めなかった.カテーテル関連血流感染はIJV群:10例(66.7%),BCV群:12例(52%)に認め,有意差はみられなかった.CVC留置期間中央値(IQR)はIJV群:273日(172～363.5),BCV群:152日(101～280)であり有意差を認めなかった.【結論】リアルタイム超音波ガイド下鎖骨上アプローチによる腕頭静脈穿刺術は小児血液・悪性固形患者に対しても安全な手技と考えられた.(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2024&ichushi_jid=J01113&link_issn=&doc_id=20240510080003&doc_link_id=10.11164%2Fjjsps.60.2_158&url=https%3A%2F%2Fdoi.org%2F10.11164%2Fjjsps.60.2_158&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Authorship：Lead author   Language：English  

A 15-year-old girl with recurrent upper abdominal pain was diagnosed with congenital biliary dilatation. Abdominal enhanced computed tomography (CT) showed the anterior segmental branch of the right hepatic artery (RHA) running across the ventral aspect of the dilated common hepatic duct (CHD). Laparoscopic extrahepatic dilated biliary duct excision and Roux-en-Y hepaticojejunostomy were planned. Intraoperatively, the dilated CHD was observed to bifurcate into the ventral and dorsal ducts, between which the anterior segmental branch of the RHA crossed through the CHD. The CHD rejoined on the distal side as one duct. We transected the CHD just above the cystic duct. The patency of the ventral and dorsal sides of the bifurcated CHD was confirmed. Laparoscopic hepaticojejunostomy was performed at the distal side of the rejoined CHD, without sacrificing the anterior segmental branch of the RHA. There was no postoperative blood flow impairment in the right hepatic lobe or anastomotic stenosis.

DOI： 10.1111/ases.13264

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Language：English   Publishing type：Research paper (scientific journal)  

Background: Endoscopic surgery also has been becoming widespread in the field of pediatric surgery. However, most disease treated by pediatric surgery in a single institution are small number of cases. Besides, the variety of operative procedures that need to be performed in this field is quite wide. For these reasons, pediatric surgeons have limited opportunities to perform endoscopic surgery. Therefore, it is difficult to introduce advanced endoscopic surgery at a single local hospital. To educate pediatric surgeons in local hospitals, for widespread advanced pediatric endoscopic surgery safely, and to eliminate the need for patient centralization, we have introduced a proctoring system. We compared the surgical results of our institution, a center hospital, with other local institutions, to investigate the feasibility of our proctoring system. Methods: The experienced pediatric surgeon of our institution visits local hospitals to provide onsite coaching and supervises pediatric surgeons on the learning curve. All patients who underwent laparoscopic cyst excision and hepaticojejunostomy for choledochal cysts, one of the advanced pediatric endoscopic surgeries was retrospectively reviewed. Results: Thirty-four cases were evaluated (14 cases in our institution, 20 cases in 9 other institutions). The procedures of all 34 cases were performed by surgeons with 0-2 cases of experience in the procedure. There were no open conversion cases. There was no significant difference in the operative date. There was 1 case (6.7%) of postoperative complications during hospitalization at our institution and 3 cases (14.3%) at other institutions (P = .47). Two cases of late complications (13.3%) occurred at our institution, whereas 6 cases (28.6%) occurred at other institutions (P = .28). Conclusion: With the proctoring system, the performance and completion of advanced pediatric endoscopic surgery at local institutions was feasible. This has important implications given the ever-growing demand for pediatric endoscopic surgery and the increasing need for competent pediatric endoscopic surgeons.

DOI： 10.1089/lap.2023.0087

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Language：Japanese   Publisher：(一社)日本周産期・新生児医学会  

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Language：Japanese   Publisher：(一社)日本周産期・新生児医学会  

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Language：Japanese   Publisher：(一社)日本周産期・新生児医学会  

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Purpose: Severely neurologically impaired patients sometimes require anti-reflux surgery with preceding gastrostomy. We apply a traction technique for laparoscopic fundoplication (LF) without gastrostomy takedown (GTD) in such cases. We conducted a multicenter review to assess the feasibility of our approach. Materials and Methods: In brief, the traction technique involves left-lateral-traction of the stomach body, right-lateral-traction of the round ligament of the liver, and elevation of the left liver lobe to create a sufficient field for manipulating the forceps. Patients who underwent LF with Nissen's procedures in 2010-2022 were retrospectively reviewed. Data were analyzed by a one-way analysis of variance. Results: The operative approaches included the traction technique (n = 16; Group 1), GTD and reconstruction (n = 5; Group 2), and LF followed by gastrostomy (n = 92; Group 3). In comparison with Group 1, significant differences were only found in pneumoperitoneum time (Group 1 versus Group 2 versus Group 3: 174.4 minutes versus 250.4 minutes versus 179.5 minutes; P = .0179). Operating time (222.7 minutes versus 303.0 minutes versus 239.7 minutes; P = .0743), duration to full-strength enteral nutrition (10.4 days versus 17.2 days versus 11.0 days; P = .0806), and length of hospital stay (17.2 days versus 31.0 days versus 18.5 days; P = .3247) were equivalent. No re-fundoplication was required in Group 1. Conclusion: The traction technique secures the operative quality and outcome of LF without GTD.

DOI： 10.1089/lap.2022.0576

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: Management of persistently patent ductus arteriosus (PDA) in extremely low-birth-weight infants (ELBWIs) requires attention due to the risk of tissue hypoperfusion. We investigated the association between PDA and gastrointestinal perforation. METHODS: We performed a retrospective chart review from 2012 to 2021. Preterm (≤ 32 weeks) ELBWIs with PDA after birth who developed necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and idiopathic gastric perforation were included; ELBWIs with congenital heart disease were excluded. Data were analyzed using chi-squared tests with Yates; correction, and Student's t test. RESULTS: Five hundred thirty-five preterm ELBWIs were analyzed, including 20 with NEC, 22 with FIP, and 1 with gastric perforation. In NEC and FIP, the ductus arteriosus remained open in 40% (4/10) and 63.6% (14/22) of cases, respectively, and cyclo-oxygenase inhibitor treatment showed poor efficacy (p = 0.492 and 0.240). The incidence of perforation in NEC (4/9 vs. 6/11, p = 0.653), mortality in NEC (3/4 vs. 3/6, p = 0.895) and FIP (6/14 vs. 3/8, p = 0.838) did not differ according to whether the PDA persisted or resolved. CONCLUSION: The presentation of PDA did not affect the mortality or morbidity of ELBWIs. However, it is essential to consider the possibility of gastrointestinal perforation due to decreased organ blood flow caused by ductal steal.

DOI： 10.1007/s00383-023-05420-2

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1111/ped.15705

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INTRODUCTION: Management of neonates with long gap esophageal atresia (LGEA) is one of the most challenging situations facing pediatric surgeons. Delayed anastomosis after internal traction for esophageal lengthening was reported as a useful technique for long gap cases. Additionally, the use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery, especially for blood perfusion validation. We report a novel technique for safe and secure anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence. PATIENT AND SURGICAL TECHNIQUE: A pregnant woman with polyhydramnios was admitted to the department of obstetrics in our hospital. At 29 weeks of gestation, ultrasound showed mild polyhydramnios and absence of the fetal stomach. A male neonate was born at 38 weeks of gestation with 21 trisomy. EA (Gross type A) was diagnosed based on an X-ray study that showed the absence of gastric bubble with a nasogastric tube showing the "coil-up" sign. Thoracoscopic internal traction and laparoscopic gastrostomy were performed on day 4 after birth. We confirmed the distance between the upper pouch and lower pouch on X-ray. On day 16 after birth, thoracoscopic anastomosis was performed. We successfully performed esophageal anastomosis without tearing the esophageal wall. Blood perfusion of the upper and lower pouch was validated after anastomosis using ICG-guided NIR fluorescence. CONCLUSION: Delayed anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence is safe and feasible.

DOI： 10.1111/ases.13098

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We describe a laparoscopic surgical technique using indocyanine green (ICG) fluorescence to identify and preserve rare arterial branching associated with pediatric congenital biliary dilatation. Congenital biliary dilatation with pancreaticobiliary maljunction was diagnosed in a 9-year-old girl, who presented with upper abdominal pain. Abdominal enhanced computed tomography (CT) showed that the accessory right hepatic artery (aRHA) branched from the posterior superior pancreaticoduodenal artery (PSPDA) and flowed through the right aspect of the dilated common bile duct (CBD) directly into the right lobe of the liver. We performed laparoscopic dilated biliary duct resection and hepaticojejunostomy, administering ICG intravenously, at a dose of 0.6 mg/kg. The ICG fluorescence overlay mode showed an aRHA running along the right side of the dilated CBD. The aRHA was dissected from the CBD without injury. After finishing the anastomosis, the beating of the aRHA was preserved, confirming that blood flow had been maintained.

DOI： 10.1007/s00595-022-02516-5

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PURPOSE: We compared cases of anemia in gastroschisis versus omphalocele and investigated this clinical question. METHODS: A multicenter study of five pediatric surgery departments in southern Japan was planned. Sixty patients were collected between 2011 and 2020, with 33 (gastroschisis: n = 19, omphalocele: n = 14) who met the selection criteria ultimately being enrolled. Anemia was evaluated before discharge and at the first outpatient visit. RESULTS: Despite gastroschisis cases showed more frequent iron administration during hospitalization than omphalocele (p = 0.015), gastroschisis cases tended to show lower hemoglobin values at the first outpatient visit than omphalocele cases (gastroschisis: 9.9 g/dL, omphalocele: 11.2 g/dL). Gastroschisis and the gestational age at birth were significant independent predictors of anemia at the first outpatient visit, (gastroschisis: adjusted odds ratio [OR] 19.00, p = 0.036; gestational age at birth: adjusted OR 0.341, p = 0.028). A subgroup analysis for gastroschisis showed that the ratio of anemia in the 35-36 weeks group (8/10, 80.0%) and the > 37 weeks group (6/6, 100%) was more than in the < 34 weeks group (0/3, 0.0%). CONCLUSIONS: Gastroschisis may carry an increased risk of developing anemia compared with omphalocele due to the difference of direct intestinal exposure of amnion fluid in utero.

DOI： 10.1007/s00383-022-05150-x

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PURPOSE: Tunneled central venous catheter (tCVC) placement plays an important role in the management of pediatric patients. We adopted a real-time ultrasound (US)-guided supraclavicular approach to brachiocephalic vein cannulation. We evaluated the outcomes of tCVC placement via a US-guided supraclavicular approach. METHODS: A retrospective study was performed for patients who underwent US-guided central venous catheterization of the internal jugular vein (IJV group) and brachiocephalic vein (BCV group) in our institution. The background information and outcomes were reviewed using medical records. RESULTS: We evaluated 85 tCVC placements (IJV group: n = 59, BCV group: n = 26). Postoperative complications were recognized in 19 patients in the IJV group (catheter-related bloodstream infection (CRBSI), n = 14 (1.53 per 1000 catheter days); occlusion, n = 1 (1.7%, 1.09 per 1000 catheter days); accidental removal, n = 3 (5.2%, 0.33 per 1000 catheter days); and other, n = 1 (1.7%, 1.09 per 1000 catheter days)) and five patients in the BCV group (CRBSI, n = 2 (0.33 per 1000 catheter days); catheter damage, n = 1 (3.8%, 1.67 per 1000 catheter days); and accidental removal, n = 2 (7.7%, 0.33 per 1000 catheter days)). In the BCV group, despite that, the incidence of postoperative complications was lower (p = 0.205) and the period of placement was significantly longer in comparison to the IJV group (p = 0.024). CONCLUSION: US-guided placement of tunneled CVC though the BCV results in a low rate of postoperative complications despite longer CVC indwelling times compared to IJV insertion. Our results suggest that BCV insertion of tunneled CVC in children may offer advantages in terms of device performance and patient safety.

DOI： 10.1177/11297298211008084

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Language：Japanese   Publisher：日本膵・胆管合流異常研究会  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2022&ichushi_jid=J05229&link_issn=&doc_id=20220912460053&doc_link_id=10.34410%2Fjspbm.45.0_110&url=https%3A%2F%2Fdoi.org%2F10.34410%2Fjspbm.45.0_110&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

INTRODUCTION: In recent years, dome resection, which preserves the splenic immunological function, has been the primary technique used to treat splenic cysts. We herein report a surgical technique using a needle grasper and indocyanine green (ICG) fluorescence to perform dome resection of a huge nonparasitic splenic cyst in a pediatric patient. PATIENT AND SURGICAL TECHNIQUE: A 13-year-old girl was incidentally diagnosed with a splenic cyst during follow-up for scoliosis. Abdominal enhanced computed tomography (CT) showed a 17 × 14 × 14 cm unifocal cyst. Laparoscopic dome resection was planned. The intraoperative findings showed that the spleen was distended, but there was no apparent prominence of the thin cyst wall on the surface of the spleen. An ICG fluorescence camera overlay revealed poor coloration in the thinning area. We punctured the area and aspirated the cyst contents. We grasped the cyst wall with a percutaneous needle grasper and dissected the cyst wall with a vessel sealing system. We placed anti-adhesion agent at the dissection line to prevent recurrence. DISCUSSION: ICG fluorescence was useful for identifying the thinning area of a splenic cyst. The use of a percutaneous needle grasper facilitated the performance of dome resection of a huge splenic cyst in a pediatric patient with minimal invasiveness and an improved cosmetic outcome.

DOI： 10.1111/ases.13052

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Language：Japanese   Publisher：(一社)日本周産期・新生児医学会  

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Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)   Publisher：Egypts Presidential Specialized Council for Education and Scientific Research  

Abstract

Background

The mortality rate of esophageal atresia (EA) has significantly improved, but late complications remain problematic. We evaluated the physical growth, late complications, and social prognosis of postoperative patients with EA who have reached 15 years of age.

Methods

EA patients who were treated at our institution from 1984 to 2003 were enrolled. The follow-up, physical growth at the last visit, late complications and treatment, academic status, and employment situation were evaluated.

Results

Twenty-nine EA patients were registered, and the 23 surviving patients (79.3%) were followed. Anthropometry at the latest visit tended to be below the standard values. Fundoplication was performed in 6 (26.1%) of 9 (39.1%) patients with gastroesophageal reflux. Anastomotic stenosis was found in 12 patients (52.2%), and 2 (8.7%) were treated with re-anastomosis. Thirteen patients were attending a regular school, and one was attending a school for disabled children. Four had jobs from 18 years of age. Follow-up was aborted during early childhood in nine patients.

Conclusions

The physical size of EA was smaller than in the healthy population of the same age. Late complications had not affected the physical growth but were sometimes recognized in adolescence. The social prognosis of the patients was largely favorable.

DOI： 10.1186/s43159-022-00185-0

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Other Link： https://link.springer.com/article/10.1186/s43159-022-00185-0/fulltext.html

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Background and Aim: The distribution of board-certified pediatric surgeons (BCPSs) in Japan is highly biased. While Prefecture M has one of the smallest numbers of BCPSs per pediatric population, neighboring Prefecture K has one of the largest numbers of BCPSs per pediatric population. We examined the effect of BCPSs population on laparoscopic surgery and postoperative management and outcomes. Materials and Methods: We compared postoperative duration to full-dose enteral nutrition, postoperative hospital stay, and complications of neurologically impaired patients who underwent laparoscopic fundoplication in two prefectures from 2006 to 2019. Results: Laparoscopic fundoplication was performed in 17 patients in Prefecture M and 63 in K. The mean operative time was 248.8 ± 79.9 minutes in Prefecture M and 260.8 ± 94.8 in K (P = .64). The median number of days to full-dose enteral nutrition was 11.5 in Prefecture M and 10 in K (P = .29). The median postoperative hospital stay was 14 days in Prefecture M and 15 days in K (P = .38). Postoperative complications occurred in 7 cases in Prefecture M and in 10 in K. The incidence was significantly higher in Prefecture M than in K (P = .041). Conclusion: Areas with insufficient numbers of BCPSs have a higher risk of complications in laparoscopic surgery than areas with sufficient numbers.

DOI： 10.1089/lap.2021.0713

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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Language：Japanese   Publisher：(一社)日本小児外科学会  

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PURPOSE: Retroperitoneal teratomas (RPTs) are rare in infants. We report our experience of treating pediatric patients with RPTs over many years at a single institution, with the aim of developing a safe and secure operative strategy for RPTs in infants. METHODS: We reviewed the medical records of patients who underwent treatment for RPTs in our institution between April, 1984 and December, 2017, to analyze their background and clinical data. The diagnosis of RPT was confirmed histologically in all patients. RESULTS: The subjects of this retrospective analysis were 14 pediatric patients (female, n = 11; male, n = 4), ranging in age from 6 days to 12 years, 11 (73.3%) of whom were under 1 year of age. Complete surgical resection was performed in all patients. The tumor ruptured during surgery in four (26.7%) patients and perioperative vessel injuries occurred in six (40.0%) patients, resulting in nephrectomy in one (6.7%). Three (20.0%) patients suffered unilateral renal dysfunction as a surgical complication. Only one patient received postoperative chemotherapy. All patients were free of disease at the time of writing. CONCLUSION: Perioperative complications are not uncommon during surgery for RPTs, despite their benign nature. Preoperative imaging evaluation is important and operative management may be challenging. Because of the favorable prognosis and the frequency of adverse events in surgery, partial resection or split excision is sometimes unavoidable. Meticulous follow-up for recurrence is required for such patients.

DOI： 10.1007/s00595-021-02327-0

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Language：Japanese   Publisher：日本臨床外科学会  

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Authorship：Lead author   Language：Japanese   Publisher：(一社)日本小児外科学会  

2歳女児。3日前から反復する嘔吐で加療されていた。急激な腹部膨満から消化管穿孔を疑われ当院へ搬送された。来院時顔面蒼白、活気不良、末梢冷感著明、脈拍数200/分、血圧60/42mmHg、呼吸数43/分とショックを呈していた。腹部造影CTで多量のfree airおよび腹水を認め、胃軸捻転の所見を認めた。胃軸捻転による消化管穿孔と診断し緊急腹腔鏡手術を行った。腹腔鏡下に胃軸捻転を解除したが、穿孔部位が同定困難で開腹へ移行した。胃体上部大彎に付着した大網を剥離したところ同部位にピンホール状の穿孔を認めた。同部位を楔状に切除し胃を腹壁に固定した。遊走脾は認めなかった。術後DIC治療と胃蠕動改善に日数を要したが徐々に回復し、術後19日目に軽快退院した。その後再発なく経過している。急性胃軸捻転に伴い胃穿孔を生じた報告が散見される。重篤化して急激な経過をたどる報告もあるため、迅速な診断と治療を必要とする。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2021&ichushi_jid=J01113&link_issn=&doc_id=20211102020040&doc_link_id=%2Fes5shoge%2F2021%2Ft05706%2F012%2F1002-1007%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fes5shoge%2F2021%2Ft05706%2F012%2F1002-1007%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

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BACKGROUND: Perivascular epithelioid cell neoplasm (PEComa) in a child is very rare. We herein report the first malignant case of PEComa developing in the liver of a pediatric patient. CASE PRESENTATION: A 10-year-old boy visited a private clinic with prolonged fever of unknown etiology. Abdominal ultrasonography was performed to evaluate the fever's origin, revealing a large tumor in the liver. He was thus referred to a nearby hospital to investigate the tumor further. Enhanced computed tomography (CT) showed a 6.8 × 5.9 × 10.5-cm solid lesion on S4 and S5. On magnetic resonance imaging (MRI), the tumor had a low signal intensity on T1 imaging and high signal intensity on T2 imaging, with partial diffusion restriction. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed a marked uptake in the mass lesion with no evidence of metastasis. The patient was negative for all tumor markers, including AFP, CEA and PIVKA-II. The results of a needle biopsy suggested hepatocellular carcinoma. The tumor's rapid growth suggested malignancy. Hepatic segmentectomy (S4 + S5 + S8) was performed. The tumor was resected en bloc with a margin. Microscopically, the tumor showed atypical spindle, polygonal or oval-shaped cells with a high nuclear grade, and vascular invasion. Immunohistochemistry was positive for alpha-smooth muscle antigen (α-SMA), human melanin black-45 (HMB-45) and melan A. The pathological diagnosis was malignant PEComa. In the 6 months after surgery, the patient complained of shoulder pain. MRI showed a dumbbell-shaped tumor at the 2nd thoracic vertebrae, which was confirmed to be bone metastasis of PEComa. After chemotherapy, including ifosfamide and doxorubicin, vertebrectomy was performed. Two years later, thoracoabdominal CT showed a 10-cm solid mass occupying the pelvis and a 15-mm nodule in the middle lobe of the right lung. Under a diagnosis of peritoneal and lung metastases, they were surgically removed and metastasis of PEComa was pathologically confirmed. Four months after the 2nd relapse, pelvic metastasis appeared again and mTOR (mammalian target of rapamycin) inhibitor was initiated. To our knowledge, this is the first report of malignant hepatic PEComa in a pediatric patient. CONCLUSION: Although extremely rare, malignant hepatic PEComa can develop in a child.

DOI： 10.1186/s40792-021-01300-w

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INTRODUCTION: The right hepatic artery crossing the ventral side of the common hepatic duct is a relatively frequent abnormality. This aberrant right hepatic artery not only interferes with dissection of the common bile duct and hepaticojejunostomy for choledochal cyst but can also cause postoperative anastomotic stenosis. CASE PRESENTATION: A 14-year-old patient presented with upper abdominal pain and was diagnosed with a choledochal cyst (Type IVA in Todani Classification) and pancreaticobiliary maljunction. Abdominal enhanced computed tomography showed aberrant right hepatic artery located at the ventral side of the common hepatic duct. Laparoscopic choledochal cyst resection and hepaticojejunostomy were planned. Intraoperative findings also showed the aberrant right hepatic artery crossing the common hepatic duct ventrally as detected on preoperative computed tomography. Laparoscopic dorsal side repositioning of the aberrant right hepatic artery was performed because it appeared to compress the common hepatic duct and risked causing postoperative anastomotic stenosis. We performed laparoscopic hepaticojejunostomy by replacing the aberrant right hepatic artery dorsally to facilitate suturing and prevent postoperative anastomotic stenosis. The postoperative course was uneventful, with no findings suggestive of anastomotic stenosis. DISCUSSION: The abnormality of the right hepatic artery is reported to be a primary cause of anastomotic stenosis after hepaticojejunostomy. Once anastomotic stenosis or stricture develops, it is often difficult to treat. The prevention of the stenosis is important. CONCLUSIONS: In choledochal cyst with aberrant right hepatic artery, dorsal repositioning is effective for preventing postoperative anastomotic stenosis and cholestasis.

DOI： 10.1016/j.ijscr.2021.106300

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PURPOSE: Necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI) are major diseases that cause gastrointestinal disorders in extremely low-birth-weight infants (ELBWIs). We conducted a review to compare the postoperative outcomes of ELBWIs with these diseases in our neonatal intensive-care unit. METHODS: A retrospective chart review of ELBWIs surgically treated for NEC (n = 31), FIP (n = 35), and MRI (n = 16) in 2001-2018 was undertaken. This period was divided into early (2001-2005), middle (2006-2010), and late (2011-2018) periods. Data were analyzed with the Cochran-Armitage test. Statistical significance was defined as p < 0.05. RESULTS: The survival rates in ELBWIs with NEC (early/middle/late: 36.4%/42.9%/61.5%; p = 0.212) and FIP (20%/50%/70.6%; p = 0.012) improved over time; all patients with MRI survived. The neuropsychological development of 24 cases was assessed with the Kyoto Scale of Psychological Development in the Postural-Motor, Cognitive-Adaptative, and Language-Social domains. The mean developmental quotient of all domains was 68.4 (range 18-95) at corrected 1.5 years of age and 69.1 (range 25-108) at chronological 3 years of age, both were considered as poor development. There was no improvement over time (p = 0.899). CONCLUSION: Ideal neuropsychological development was not observed with the improvement of survival rate. Less-invasive surgical intervention and adequate postoperative care are required to encourage further development.

DOI： 10.1007/s00383-020-04825-7

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AIM OF THE STUDY: We previously showed an increased number of smaller portal vein (PV) branches in the portal areas of liver biopsy specimens of biliary atresia (BA) patients. We evaluated the correlation between this histopathological feature and the prognosis. PATIENTS AND METHODS: Twenty-five consecutive patients with BA encountered between 2000 and 2012 were classified into three prognostic groups based on their postoperative outcomes: Excellent (n = 11) for native-liver survivors with a normal liver function, Good (n = 6) for native-liver survivors with liver dysfunction, and Poor (n = 8) for survivors after liver transplant or on a waiting list. Data from morphometrical analyses, including the fibrotic portal area, numbers of PVs, diameter and total area of PV branches, were statistically compared among the three groups. MAIN RESULTS: The number of PV branches per unit area of the whole-liver specimen in the poor prognostic group was significantly lower than that in the excellent group (3.1 ± 0.6 vs. 5.2 ± 2.0/mm2, p = 0.03). There were no significant differences in the other parameters. CONCLUSIONS: This is the first report on the relationships between morphometrically analyzed PV branches and the postoperative course in BA patients. The portal venous system is involved as the primary lesion in BA.

DOI： 10.1007/s00383-019-04579-x

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Language：Japanese   Publisher：(一社)日本小児外科学会  

先天性門脈体循環シャント(以下、本症)は肝肺症候群や肝性脳症などを生じる疾患でシャント血流遮断が根治治療となる。今回、異なるアプローチで治療した本症3例を経験した。1例は1歳女児で腹腔鏡下肝切除によるシャント血管遮断術を施行。2例目は心疾患合併の10ヵ月男児で開腹でシャント血管バンディングを施行。3例目は17歳男児でコイル塞栓術を施行した。本症は肺高血圧など重篤な合併症の可能性があり積極的に治療すべきであるが、年齢・病型も異なり標準的な治療アプローチが存在しない。肝内門脈の低形成が軽度で閉塞試験で門脈圧25mmHg未満の症例は一期的血流遮断の適応、肝内門脈が著しく低形成もしくは門脈圧25mmHg以上の症例は二期的血流遮断の適応としている。術式は低侵襲なinterventional radiology(IVR)が望ましいがシャント血管の位置や肝内門脈の形成程度などを複合的に考えて選択すべきである。(著者抄録)

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Background and Aim: Training programs for developing laparoscopic suturing skills range from dry-box training to virtual simulator training. There are advantages and disadvantages to each training method; however, which training is best for medical students and young surgeons is unclear. The aim of this study was to compare the proficiency of medical students in acquiring laparoscopic suturing skills after various routes of short-term training: via a video, an expert teacher, or a virtual simulator. Materials and Methods: Seventeen medical students were registered and divided randomly into three groups: group receiving personal training while watching a training video (video group), group receiving training under the guidance of an expert (teaching group), and group receiving personal training with a virtual simulator (virtual group). The students practiced laparoscopic suturing and tying skills for 1 hour. Following their training, they performed the evaluation task of three sutures and ties using a laparoscopic fundoplication simulator. We developed a 1-year-old infant body model (body weight 10 kg) based on computed tomography data and established a pneumoperitoneum body model based on a clinical situation. Results: The path length of the assistant forceps in the virtual group tended to be longer than in the other groups. The average acceleration of the assistant forceps in the virtual group was faster than in the other groups (P = .04). There were no significant differences in the other evaluation parameters. Conclusion: A long-term and combination training study should be performed to develop the best method for training medical students and inexperienced young surgeons.

DOI： 10.1089/lap.2019.0212

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PURPOSE: This study assessed the impact of 2D and 3D environments by comparing pediatric surgeons (PS) and gastrointestinal surgeons (GIS) using a laparoscopic hepaticojejunostomy simulator. METHODS: We developed a high-fidelity simulator of laparoscopic hepaticojejunostomy. Thirty-five participants (19 PS and 16 GIS) performed hepaticojejunostomy in both 2D and 3D environments. We evaluated the required time, total path length, and average velocities of bilateral forceps in both situations using the para-axial port layout. RESULTS: Regarding the participants' characteristics, the performance history of laparoscopic hepaticojejunostomy differed significantly between PS and GIS. In PS, the 3D environment did not markedly affect compared with 2D. In GIS, however, the 3D environment affected the time and movement of the right forceps. There were no significant differences in the time between PS and GIS in either environment. In both environments, the right-hand movement of the PS group was shorter and slower than that of the GIS group, but the left-hand movement was the opposite. CONCLUSION: There were significant differences in forceps movement characteristics between the PS and GIS. The effects of a 3D environment could not be clarified in this study, because it may depend on the port layout used and the operative procedures.

DOI： 10.1007/s00383-019-04538-6

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Purpose: Various studies have shown the benefit of three-dimensional (3D) systems over two-dimensional (2D) systems in endoscopic surgery. However, few studies have focused on pediatric endosurgery. The purpose of this study was to assess the impact of 2D and 3D environments on the time taken and forceps manipulation by comparing experts and trainees using a laparoscopic hepaticojejunostomy simulator. Methods: We have developed a simulator of laparoscopic hepaticojejunostomy for congenital biliary dilatation. Seventeen participants of pediatric surgeons (4 experts and 13 trainees) performed hepaticojejunostomy using our simulator in both 2D and 3D environment. We evaluated the required time, total path length, and average velocities of bilateral forceps in both situations. Results: Obtained results show the findings for the required time (seconds; 2D, experts: 810.43 ± 321.64 vs. trainees: 1136.02 ± 409.96, P = .17) (seconds; 3D, experts: 660.21 ± 256.48 vs. trainees: 1017 ± 280.93, P = .039), total path length of right forceps (mm; 2D, experts: 38838.23 ± 30686.63 vs. trainees: 52005.47 ± 31675.02, P = .48)(mm; 3D, experts: 24443.09 ± 12316.32 vs. trainees: 45508.09 ± 26926.27, P = .16), total path length of left forceps (mm; 2D, experts: 131635.54 ± 71669.94 vs. trainees: 245242.48 ± 130940.25, P = .48)(mm; 3D, experts: 88520.42 ± 56766.63 vs. trainees: 230789.75 ± 107315.85, P = .024), average velocities of right forceps (mm/second; 2D, experts: 44.80 ± 21.85 vs. trainees: 44.37 ± 18.92, P = .97) (mm/second; 3D, experts: 37.28 ± 16.49 vs. trainees: 42.58 ± 14.40, P = .54), average velocities of left forceps (mm/second; 2D, experts: 156.65 ± 38.69 vs. trainees: 202.58 ± 63.80, P = .20) (mm/second; 3D, experts: 125.64 ± 44.30 vs. trainees: 219.42 ± 43.82, P < .01). Conclusion: The experts performed more effectively when using the 3D system. Using 3D, the total path length of the left forceps of expert pediatric surgeons was significantly shorter than trainee pediatric surgeons, and the average velocities of the left forceps tip of expert pediatric surgeons was significantly slower than trainee pediatric surgeons. These results suggest that training of assisting hand is necessary for advanced pediatric endosurgery to avoid organ injury.

DOI： 10.1089/lap.2019.0211

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Language：Japanese   Publisher：(一社)日本小児救急医学会  

【目的】小児腸重積症に対する超音波下整復術とX線透視下整復術の有用性と安全性を比較検討する。【対象と方法】腸重積症に対して超音波下整復術を実施した41名(US群)とX線透視下整復術を実施した82名(FS群)について、後方視的に検討した。【結果】初回整復率はUS群100%、FS群83.5%とUS群の方が有意に高かった(p=0.009)。整復率、再発率、手術を要した割合、整復に要した時間には両群間で差はなかった。両群とも有害事象はなかった。【結論】超音波下整復術は、放射線被曝を回避でき、有効かつ安全である。超音波下整復術は腸重積症の非観血的整復術の第一選択となる可能性がある。(著者抄録)

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PURPOSE: Many kinds of operative procedures have been proposed for anorectal malformation (ARM) patients. At our institution, sacroperineal or sacroabdominoperineal anorectoplasty (SP-SAP) have been performed from 1984 to 2007. The aim of this study is clarify the change over the time in the postoperative bowel function in male ARM patients. METHODS: Patient data were collected from 1984 to 2007. Fifty-two male patients with high- and intermediate-type ARM were enrolled. The patients' characteristics and bowel function were reviewed and analyzed retrospectively. The bowel function was evaluated according to the evacuation score (ES) of the Japan Society of ARM Study Group. RESULTS: The operative procedures were SP-SAP in 52 male patients. The total ES improved chronologically and significantly until 11 years of age. Regarding the clinical stratification of the ES, the ratio of "excellent" and "good" results was over 91.9% at 11 years of age. A satisfactory bowel movement score was achieved by 9 years of age. The constipation, incontinence and soiling scores improved slowly but continuously until 11 years of age. CONCLUSION: The ES showed continuous improvement after a definitive operation. An understanding of the characteristics of improvement is very important in managing the postoperative bowel function in ARM patients.

DOI： 10.1007/s00383-019-04540-y

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DOI： 10.1111/ped.13902

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Purpose: An early diagnosis of ovarian torsion is sometimes difficult due to variable clinical symptoms and non-specific imaging findings. We retrospectively reviewed patients with pediatric ovarian masses manifesting torsion. Methods: Fifty-eight ovarian masses (55 episodes) in 49 non-neonatal patients treated from April 1984 to March 2017 were retrospectively analyzed. The Mann-Whitney U test and Fisher's exact test were used for the statistical analysis. Results: The median age of these 55 episodes was 10.5 years old (range 1.0-23.0). Thirty-three patients presented with abdominal pain. Forty-five tumors and 13 cystic masses were resected and diagnosed pathologically (50 benign and 8 malignant). Torsion was identified in 15 cases (25.9%) at operation. The torsion masses were all benign, and 8 ovaries (53.3%) were successfully preserved. Comparing the torsion cases with the nontorsion cases, only the white cell count was significantly higher in the torsion cases (p=0.0133) and in the patients presented with abdominal pain (p=0.0068). The duration of abdominal pain was significantly shorter in ovary preserved cases than in oophorectomy cases. Conclusion: The white blood cell may be a helpful indicator of the presence of torsion as well as the need for surgery.

DOI： 10.1136/wjps-2018-000009

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PURPOSE: Late postoperative complications in choledochal cyst (CC) patients are severe problems that affect the quality of life (QOL). We evaluated the postoperative complications and health-related QOL (HRQOL) of CC patients ≥ 18 years of age. METHODS: From April 1984 to January 2018, 114 CC patients underwent definitive surgery at our institution. Seventy-nine patients reached ≥ 18 years of age. The HRQOL was assessed using the Japanese version of the SF-36v2. Eight health domain (physical functioning, role-physical, body pain, general health, role-emotional, vitality, mental health, and social functioning) scores and three component summary [physical component summary, mental component summary (MCS), and role-social component summary] scores were compared between the patients with and without complications (C [+] vs. C [-]). RESULTS: Thirty-five patients answered the questionnaires. Twelve patients had postoperative complications. Among the eight domains, the score of general health was significantly lower in C [+] patients than in C [-] patients (p = 0.0488). Among the three component scores, the MCS score in C [+] patients was lower than in C [-] patients without significance (p = 0.0953). CONCLUSIONS: The HRQOL of CC patients ≥ 18 years of age was mostly acceptable. However, postoperative complications can impair the sense of well-being and affect the mental health.

DOI： 10.1007/s00383-019-04456-7

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BACKGROUND: Single-incision laparoscopic surgery has emerged; however, the procedures might be complicated for trainees. We compared the clinical outcomes of conventional three-port laparoscopic appendectomy (CLA) and single-incision and one-puncture laparoscopic appendectomy (SIOPLA) by attending pediatric surgeons (APSs) and surgeons in training (SITs). MATERIALS AND METHODS: We reviewed the clinical outcomes of 72 randomized laparoscopic appendectomies that were consecutively performed by SITs and APSs for a 2-year period. The cases were categorized according to type of surgeon. Finally, 10 CLA and 18 SIOPLA procedures were performed by SITs, and 24 CLA and 20 SIOPLA procedures were performed by APSs. The operative time, blood loss, analgesic use, complications, and hospital stay were analyzed. RESULTS: There were no significant differences in any of the evaluation points between CLA and SIOPLA. CONCLUSIONS: SIOPLA is not inferior operation to CLA, and the postoperative outcomes of SIOPLA were satisfactory. Thus, SIOPLA was safe and feasible for young surgeons to perform.

DOI： 10.1089/lap.2018.0195

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AIMS AND OBJECTIVES: Fish oil (FO) lipid emulsion and a new lipid emulsion (SMOF) are important treatments for intestinal failure-associated liver disease. We evaluated the efficacy of FO and SMOF lipid emulsion on intestinal mucosal adaptation using a total parenteral nutrition (TPN)-supported rat model of short bowel syndrome. MATERIAL & METHODS: Sprague-Dawley rats underwent jugular vein catheterization and 90% small bowel resection and were divided into three groups: TPN with soy bean oil lipid emulsion (SO group), FO lipid emulsion (FO group), or SMOF (SMOF group). On day 13, the rats were euthanized, and the small intestine was harvested. The microscopic morphology and crypt cell proliferation rate (CCPR) were then evaluated. RESULTS: The villus height of the ileum in the SMOF group was significantly higher than in the SO group. The crypt depth of the intestine in the SMOF group was significantly lower than in the SO group. The CCPRs of the intestine in the FO and SMOF groups were both higher than in the SO group. CONCLUSIONS: Lipid emulsion affected the bowel morphology, such as the mucosa as well as the intestinal smooth muscle. Further studies are needed to clarify the mechanisms.

DOI： 10.1016/j.jpedsurg.2018.08.019

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PURPOSE: While the diagnosis and outcomes of esophageal atresia (EA) have improved, associated anomalies, the management of late complications and growth remain major issues. We analyzed factors that affected the prognosis, late complications and growth. METHODS: We retrospectively reviewed EA patients treated at two centers from 1984 to 2016. Patient characteristics, complications (gastroesophageal reflux [GER], anastomotic stenosis, tracheomalacia, dysphagia) and growth were evaluated. RESULTS: Seventy-three EA patients were treated (overall survival rate:80.8%). The mean birth weight was 2514 ± 509 g in the surviving group, and 2453 ± 567 g in the fatal group excluded chromosomal abnormality (p = 0.76). Cardiac and chromosomal anomalies significantly affected mortality. Postoperative GER and anastomotic stenosis each occurred in 39% of the patients. Only GER was significantly affected by the Gross classification. The standard deviation (SD) values of the EA patients' growth were all lower than in the normal population. The SD of body weight was significantly lower in patients with extremity anomalies. CONCLUSIONS: Associated cardiac and chromosomal anomalies significantly affected the prognosis. GER and anastomotic stenosis were the most common late complications. The growth of the surviving cases was insufficient. These factors will help optimize the therapeutic strategies and postoperative management for EA.

DOI： 10.1007/s00383-018-4326-1

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PURPOSE: The late postoperative complications of choledochal cyst (CC) surgery are serious and include intrahepatic stones and biliary carcinoma; therefore, long-term follow-up is crucial. METHODS: The subjects of this retrospective study were patients who underwent surgery for CC at Kagoshima University Hospital between April, 1984 and December, 2016. We analyzed the operative results, early and late postoperative complications, and postoperative follow-up rate. RESULTS: The study population comprised 110 CC patients (male/female: 33/77) with a median age at surgery of 4 years, 3 months (range 12 days-17 years). The patients underwent hepaticoduodenostomy (n = 1; 0.9%) or hepaticojejunostomy (n = 109; 99.1%). Late complications included intrahepatic bile duct (IHBD) dilatation (n = 1; 0.9%), IHBD stones (n = 3; 2.7%), and adhesive ileus (n = 4; 3.6%). There was no incidence of biliary carcinoma in this series. The rates of follow-up at our institute within 10 years of surgery and more than 20 years after surgery were 69.2% (18 of 26) and 14.5% (8 of 55), respectively. CONCLUSIONS: The follow-up rate after definitive surgery declined with time. Late complications were observed within 20 years, but biliary carcinoma was not observed. The follow-up rate should be increased to detect late complications. Moreover, patient education on long-term follow up is essential to prevent life-threatening events after definitive surgery for CC.

DOI： 10.1007/s00595-018-1660-9

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BACKGROUND: Since short bowel syndrome (SBS) patients face life-threatening conditions, the development of therapeutic strategies to induce intestinal adaptation has been investigated. Ghrelin, a ligand of growth hormone (GH) secretagogue-receptor that stimulates the release of GH and insulin like growth factor-1 (IGF-1), has several pleiotropic effects. We investigated whether ghrelin induces intestinal adaptation in parenterally fed rats with SBS. METHODS: Sprague-Dawley rats underwent venous catheterization and were divided into 3 groups: those receiving 90% small bowel resection while leaving the proximal jejunum and distal ileum (90% SBR) with TPN (SBS/TPN group), those receiving 90% SBR with TPN + ghrelin (SBS/TPN/ghrelin group), and those receiving sham operation and fed chow (sham group). Ghrelin was administered intravenously at 10 μg/kg/day. On Day 13, the rats were euthanized and the small intestine harvested, and the histology and crypt cell proliferation rates (CCPR), apoptosis, and nutrient transporter protein levels were analyzed and the plasma hormones were measured. RESULTS: The villus height and crypt depth of the ileum in the SBS/TPN/ghrelin group were significantly higher than in the SBS/TPN group. The CCPR of the jejunum and the ileum significantly increased by the administration of ghrelin; however, the apoptosis rates did not significantly differ between the SBS/TPN and SBS/TPN/ghrelin groups. Significant differences did not exist in the plasma IGF-1 and nutrient transporter protein levels among three groups. CONCLUSIONS: The intravenous administration of ghrelin stimulated the morphological intestinal adaptation of the ileum to a greater degree than the jejunum due to the direct effect of ghrelin.

DOI： 10.1016/j.peptides.2018.06.009

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PURPOSE: Pediatric patients with intestinal failure need long-term parenteral nutrition (PN), but this nutritional support causes liver dysfunction, such as intestinal failure-associated liver disease (IFALD). Several studies have shown that the lipid emulsion produced by soybean oil (SO) is associated with the occurrence of IFALD. In this study, we evaluated the effect of SO and fish oil (FO) lipid emulsion on hepatic steatosis. METHODS: Sprague-Dawley rats underwent jugular vein catheterization and were divided into three groups: sham operation with normal chow (Sham group), 80% small bowel resection (80% SBR) + TPN with SO lipid emulsion (SO group), and 80% SBR + TPN with FO lipid emulsion (FO group). All rats were euthanized and the serum biochemistry and hepatic histology analyzed. RESULTS: No significant differences in the serum liver or biliary enzymes were noted between the SO and FO groups. The pathological findings and NAFLD score in the FO group did not show steatosis and were significantly lower than in the SO group. An analysis of the fatty acids profile in the both the SO and FO groups did not indicate essential fatty acid deficiency (EFAD). CONCLUSION: FO lipid emulsion may have a protective role against steatosis of IFALD without EFAD.

DOI： 10.1007/s00383-017-4190-4

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BACKGROUND/PURPOSE: Hirschsprung disease (HD) is considered curable, but the postoperative bowel function is not always satisfactory. In this study, we evaluated the general condition, bowel function, and social performance in adults who were older than 17years of age who had undergone definitive operations in childhood. METHOD: From 1984 to 2016, 110 patients with HD underwent definitive surgery at our institute. Sixty-three patients who had undergone the transabdominal Soave procedure reached 18years of age. Their present status and symptoms, anorectal function, genitourinary function, and social performance were evaluated during the clinical follow-up via a questionnaire survey. RESULT: The mean age of the questionnaire respondents was 25.0 (19-37) years. The bowel function was mostly good. However, 56% of patients had abdominal pain more than once a week. Regarding evacuation symptoms, incontinence and soiling occurred in 18.7%. Among the respondents 33.3% were married, and 60% of those who were married had children. The respondents had achieved success in their education and professional careers. CONCLUSION: The bowel function of most patients was satisfactory, although some had chronic abdominal symptoms. Pediatric surgeons should continue trying to achieve complete bowel function after definitive surgery of HD. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: Level III.

DOI： 10.1016/j.jpedsurg.2017.08.036

PubMed

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PURPOSE: Short-bowel syndrome (SBS) is associated with high morbidity and mortality. We conducted this study to establish the predictors of survival and weaning off parenteral nutrition (PN). METHODS: We reviewed the medical records of 16 SBS infants treated at our institution within a 30-year period. SBS was defined as a residual small-bowel length (RSBL) of <75 cm. Loss of the ileocecal valve (ICV), cholestasis (D-Bil >2.0 mg/dl), enterostomy, and RSBL were all evaluated. Kaplan-Meier analysis was used to analyze the predictors. RESULTS: The mean RSBL was 34.9 ± 22.9 cm. Six patients died (37.5%) and nine patients were weaned off PN (56.3%). Significant differences were observed in cholestasis (p < 0.03), enterostomy (p < 0.01), an absolute RSBL of <30 cm (p < 0.04), and a percentage of expected RSBL of <10% (p < 0.04) as survival predictors. Significant differences were also observed for cholestasis (p < 0.01), loss of the ICV (p < 0.04), an absolute RSBL of <20 cm (p < 0.01), and a percentage of expected RSBL of <10% (p < 0.03) as predictors of weaning off PN. CONCLUSION: These predictors may help us select the optimal treatments for pediatric patients with SBS.

DOI： 10.1007/s00595-017-1534-6

PubMed

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Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: We compared the characteristics and precision of right and left needle driving for right-handed pediatric surgeons using a laparoscopic diaphragmatic repair model. METHODS: Eighteen right-handed pediatric surgeons performed three needle driving maneuvers using both hands. We evaluated the required time and conducted an image analysis. The total path length, velocity, and acceleration of the needle driving were also evaluated. RESULTS: Obtained results show the findings for the required time (s, Rt 310.78 ± 148.93 vs. Lt 308.61 ± 122.53, p = 0.93), sum of needle driving balances (mm, Rt 5.23 ± 2.44 vs. Lt 5.05 ± 3.17, p = 0.83), the gap of the needle driving interval (Rt 1.2 ± 0.93 vs. Lt 2.17 ± 1.67, p = 0.04), total path length (mm, Rt 594.03 ± 205.29 vs. Lt 1641.07 ± 670.68, p < 0.01), and average velocity (mm/s, Rt 1.92 ± 0.54 vs. Lt 5.3 ± 1.39, p < 0.01). CONCLUSION: For right-handed pediatric surgeons, left needle driving showed almost same quality of right needle driving as regarding the precision. But left needle driving also showed too fast but not economical movement unfortunately, implying rough and risky forceps manipulation. Non-dominant hand training is necessary to avoid organ injury.

DOI： 10.1007/s00383-017-4144-x

PubMed

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Language：Japanese   Publisher：(一社)日本外科感染症学会  

本邦発の国際的な急性胆管炎・胆嚢炎診療ガイドラインであるTG13では、診療上遵守されるべき項目をまとめて表示するbundleが設定された。bundle設定前と設定後で当院での急性胆嚢炎の診療の変化、成績とその妥当性を検討した。当院で2009年1月から2013年12月までに経験した急性胆嚢炎143例をbundle設定前110例、後33例の2群にわけ、bundleの各項目(1～11)の遵守率を確認し、bundle設定前後での診療成績を検討した。両群間の背景の性別、年齢、重症度等に差は認めなかった。bundle全体の遵守率は、設定後の群で有意に高かった。各項目間ごとの遵守率の比較では、項目番号5(Grade I(軽症)症例の発症から72時間以内の胆嚢摘出術を検討)、項目番号6(軽症例の24時間後の治療)と9(血液と胆汁の培養検査)で、設定前群の遵守率が低かった。治療結果では、死亡例は両群間ともなかったが、設定後群で有意に入院日数が短縮された。手術施行例の術後合併症の頻度も両群間に有意な差は認めなかった。急性胆嚢炎の診療において設定されたTG13でのbundle設定は、各主治医がガイドラインを参照してbundleの項目ごとに遵守しようとの意識の向上をもたらし、bundleの遵守率が高くなり、結果的に治療効果が高まる可能性がある。単施設での検討は症例数の限界があり、多施設での手術実施時期等の前向き臨床試験の実施が望まれる。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2014&ichushi_jid=J04188&link_issn=&doc_id=20140718470005&doc_link_id=%2Fdg9srgif%2F2014%2F001103%2F006%2F0211-0215%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdg9srgif%2F2014%2F001103%2F006%2F0211-0215%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：日本救命医療学会  

【目的】鈍的胸部外傷における多発外傷症例について検討した。【対象と方法】過去12年間の鈍的胸部外傷入院228例中、解剖学的重症度(Abbrebiated Injury Score:AIS)3以上の症例は137例であった。このうち他部位にAIS3以上の損傷を伴う多発外傷は30例(21.9%)で、これらを対象とし胸部の単独外傷107例(78.1%)と比較しながら受傷機転・損傷形態・治療・予後を検討した。【結果】男性18例、女性12例、平均年齢50.4歳(18-79歳)で単独外傷と差を認めず、受傷機転では挟圧が有意に高頻度であった。損傷形態は血胸・血気胸20例、気胸5例、肺挫傷3例、多発肋骨骨折2例で差を認めなかった。胸部以外の損傷部位は頭部15例、四肢9例、腹部8例、骨盤3例(重複を含む)であった。AIS平均3.73、多発外傷重症度スコア(Injury Severity Score:ISS)平均30.67で共に多発外傷で高値であった。治療は胸腔ドレナージ20例、保存的観察6例、手術4例、治療内容に差は認めなかったが多発外傷の手術症例は全例緊急手術で単独外傷より有意に高頻度であった。合併損傷を伴うIII型横隔膜破裂が3例で縫合閉鎖に加え損傷部の治療(脾摘1例、胃縫合閉鎖1例、腎止血及び開頭減圧1例)を、1例は胸壁出血に対する開胸止血と外傷性クモ膜下出血の保存的治療を行った。死亡例は4例で損傷部の出血制御不可3例(後腹膜、腎臓、胸腔内+頭蓋内)と脳挫傷1例であった。死亡率は13.3%で単独外傷に比し有意に上昇した。【考察】鈍的胸部外傷ではドレナージや経過観察で軽快する症例も多いが、多発外傷の場合単独外傷に比し受傷直後の緊急手術の頻度が増すこと、死亡率が上昇し他部位損傷が死亡原因の多くを占めることもあり、診療中は常に全身に対する検索を怠らず正確で迅速な診断と処置を心がける必要がある。(著者抄録)

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Language：Japanese   Publisher：(一社)日本小児外科学会  

【目的】先天性空腸狭窄症は比較的稀な疾患で腸閉鎖・狭窄症の約5%をしめる。集計報告はみられず自験例および報告例を集計しその臨床像を明らかにする。【対象と方法】診療録をもとに自験例4例の周産期情報、臨床経過を集計した。また自験例と報告例16例の新生児期症状、診断時年齢、初発症状、狭窄部位、狭窄様式、診断方法、治療法を集計した。【結果】自験例4例の結果:1例の出生前超音波検査で腸管拡張を認めたが、それ以外の周産期異常はなかった。診断時年齢は、月齢0～月齢7で、新生児期に診断された症例は1例のみであった。診断時体重は2,794g(-2.8SD)、6,685g(-1.5SD)、2,970g(-3.6SD)、5,868g(-2.1SD)であった。全例で嘔吐と体重増加不良を認めた。上部消化管造影で診断がなされ全例で手術が行われた。1例では術後狭窄に対してバルーン拡張が行われた。報告例を含めた20例の結果:記載のある全例が上部空腸の狭窄であり、大半が膜様狭窄であった。新生児期より嘔吐を認めた10例中3例のみが新生児期に診断された。11例は乳幼児期に嘔吐・腹部膨満・体重増加不良を契機に精査が行われ診断に至っていた。上部消化管造影は13例に行われ、このうち2例は十二指腸造影も行われた。1例は、シネMR撮像法で診断されていた。治療は1例で内視鏡的治療が施行された。記載のある13例で手術が施行され重篤な合併症の報告はなかった。【結論】空腸狭窄は先天異常であるが新生児期に診断される症例は少ない。乳児期に繰り返す嘔吐や体重増加不良を認めた場合は、本症も念頭に置き上部消化管造影や十二指腸造影検査を行う必要がある。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2013&ichushi_jid=J01113&link_issn=&doc_id=20130423090001&doc_link_id=%2Fes5shoge%2F2013%2F004902%2F001%2F0195-0200%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fes5shoge%2F2013%2F004902%2F001%2F0195-0200%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(一社)日本小児外科学会  

【目的】急性虫垂炎の術前超音波検査における糞石像の、手術適応や保存的治療後の再発などにおける臨床的意義について検討する。【対象と方法】2005年1月から2010年2月の間に急性虫垂炎と診断された15歳以下の小児のうち、初発で、超音波検査による治療方針の決定がなされ、かつ糞石像の有無の記載があった219人を対象とした。手術適応は、糞石の有無とは独立して過去の報告に記載されている超音波検査での診断基準により決定した。手術例については病理所見、非手術例については入院後の転帰、退院後の再発について後方視的に検討し、術前超音波検査での糞石像の有無が手術適応・手術時病理所見や再発の有無などにどの程度影響しているかを明らかにした。【結果】腹部超音波で糞石像あり群の83%(74/89)を手術適応と診断し、そのうち81%(60/74)を病理診断で壊疽性と診断した。一方、糞石像なし群では42%(54/130)が手術適応と診断され、67%(36/54)が壊疽性であった。また、糞石の有無に関わらず、超音波検査で手術適応でないと診断された群は、保存的に治癒し退院した。退院後再発率に両群間で有意差はなかった。【結論】腹部超音波検査での糞石像陽性例は手術適応となる可能性が糞石像陰性例より高く、糞石像を認めれば手術適応である可能性は高いと言えた。しかし、糞石像ありでも保存的に治癒する例もあり、また再発率にも差はないことから、糞石像のみで手術適応とすることは避けるべきであると考える。(著者抄録)

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Language：Japanese   Publisher：(一社)日本小児外科学会  

【目的】当科で過去11年間に施行した臍ヘルニアに対する臍形成術について、我々の行っている臍形成術の有用性を含めた治療成績の検討を行った。【対象と方法】1998年1月より2008年12月までの11年間に当院で臍ヘルニアの手術を行った160例(男児94例、女児66例)を対象として、手術年齢、年間の手術件数、術後合併症、アンケート調査による満足度をretrospectiveに検討した。【結果】手術時期は6歳以下が全体の90%以上を占めた。また年間手術症例数は当初は10例ほどであったが、2004年以降、徐々に増加傾向であった。合併疾患としては鼠径ヘルニアが14例(8.75%)と最も多かった。術後合併症は創の発赤が23例(14.4%)と最多であり、ついで滲出液持続、皮下出血であった。創感染は8例(5.0%)、創離開は6例(3.8%)であった。また患者家族にアンケートを行い、89名からの回答を得た。患者家族が理想と思う臍形態は縦型(76.4%、p<0.001)であり、我々の術式による満足度調査では、74.2%(p<0.001)が満足と回答した。【結論】臍形成は機能面よりも美容面の評価が重要であり、患者やその家族の評価が非常に重要である。今回の検討により臍に対する美容意識が上昇していることと、我々が行ってきた術式は満足度の高いものであるということが判明した。一方で突出が強く余剰皮膚の多い症例では皮膚切除が必要であることが示唆された。(著者抄録)

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Authorship：Lead author   Language：English   Publishing type：Article, review, commentary, editorial, etc. (scientific journal)  

Biliary atresia (BA) is an inflammatory disease of the biliary system in newborns and infants. The etiology is largely unknown. Approximately half of BA patients require liver transplantation by 20 years of age, even after surgical correction due to progressive fibrosis of the liver. Regarding the disease mechanism, there is circumstantial evidence to support the hypothesis of graft-versus-host disease because of the existence of maternal cells in the liver (maternal microchimerism, MMC), histopathological similarity of the liver and an intense maternal response to the BA patient with mixed lymphocyte culture. Immune dysregulation with decreased Treg and increased Th1 and Th17 cells are the pathogenic features of BA, which are homologous to the pathogenic features of GvHD. Further elucidation of the etiopathogenetic mechanism of BA is warranted for development of new therapeutic strategies for native liver survival.

DOI： 10.1016/j.transci.2022.103410

PubMed

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Biliary atresia (BA) is a fibroinflammatory cholangiopathy and portal venopathy. It is of unknown etiology and is associated with systemic immune dysregulation, in which the first insult begins before birth. Maternal microchimerism is a naturally occurring phenomenon during fetal life in which maternal alloantigens promote the development of tolerogenic fetal regulatory T-cells in utero. However, maternal cells may alter the fetus's response to self-antigens and trigger an autoimmune response under certain histocompatibility combinations between the mother and the fetus. A recent report on a set of dizygotic discordant twins with BA, one of whose placentae showed villitis of unknown etiology, implies a certain immune-mediated conflict between the fetus with BA and the mother. Maternal chimeric cells persist postnatally for various time spans and can cause cholangitis, which ultimately leads to liver failure. In contrast, patients who eliminate maternal chimeric cells may retain their liver function.

DOI： 10.3389/fped.2022.1007987

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(株)東京医学社  

当院で外科手術を行った膵SPN(Solid-Pseudopapillary neoplasm)症例4例について検討した。初回の手術時年齢は8～15歳で、全例が学童期以降であった。男女比は1:3と女児に多く、原発腫瘍の占拠部位は膵鉤部が1例、膵体部が3例であった。初回手術は脾臓合併膵体尾部切除術、腫瘍核出術、腹腔鏡下脾臓温存膵体尾部切除術、脾臓合併膵尾部切除術が各1例であった。術後の再発は2例で認め、うち1例は試験開腹術を行った。他の1例は腫瘍核出術を行ったが、再々発をきたし膵頭十二指腸切除術が行われた。術後合併症は2例でみられ、それぞれ癒着性イレウス、膵液瘻であり、入院加療を要した。予後は全例が生存中であった。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2019&ichushi_jid=J00645&link_issn=&doc_id=20190617130016&doc_link_id=%2Faq9syoge%2F2019%2F005106%2F016%2F0614-0621%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faq9syoge%2F2019%2F005106%2F016%2F0614-0621%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(株)東京医学社  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2019&ichushi_jid=J00645&link_issn=&doc_id=20190604090008&doc_link_id=%2Faq9syoge%2F2019%2F005105%2F008%2F0457-0463%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faq9syoge%2F2019%2F005105%2F008%2F0457-0463%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(一社)日本外科学会  

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Authorship：Lead author   Language：Japanese   Publishing type：Article, review, commentary, editorial, etc. (scientific journal)   Publisher：(株)東京医学社  

先天性食道閉鎖症に対し新生児期に手術を行い、15歳以上に至った29例を対象に、身体発育状況(身長、体重、BMI)、晩期合併症、社会的予後、フォローアップ状況を後方視的に評価した。その結果、身長、体重およびBMIが同年齢の日本人の平均より低い傾向にあった。乳児期に5例、幼児期に1例が死亡し、残り23例の晩期合併症は胃食道逆流症が9例(39.1%)で、うち6例に噴門形成術を施行した。また、噴門部狭窄を12例(52.2%)に認め、うち11例にバルーン拡張を行い、うち2例に狭窄部切除端々吻合を追加した。中学卒業以降までフォローアップを継続した症例は7例で、うち6例(85.7%)が普通科高校に進学し、他の1例は養護学校に進学した。高校以上を卒業した5例中4例が就職していた。16歳以降までフォローアップを継続できた症例は7例(30.4%)であった。患児の長期QOLと社会的予後を良好に保つためには、思春期以降も定期的な経過観察が必要と考えられた。

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Language：Japanese   Publisher：(株)東京医学社  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2018&ichushi_jid=J00645&link_issn=&doc_id=20181120060003&doc_link_id=%2Faq9syoge%2F2018%2F005011%2F003%2F1089-1093%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faq9syoge%2F2018%2F005011%2F003%2F1089-1093%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(株)東京医学社  

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Language：Japanese   Publisher：(株)東京医学社  

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Language：Japanese   Publisher：(株)東京医学社  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2018&ichushi_jid=J00645&link_issn=&doc_id=20180201050003&doc_link_id=%2Faq9syoge%2F2018%2F005001%2F004%2F0016-0020%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faq9syoge%2F2018%2F005001%2F004%2F0016-0020%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(株)オプトロニクス社  

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Language：Japanese   Publisher：(株)ジェフコーポレーション  

小児短腸症候群に対する栄養管理は、原因疾患に対する手術を行った直後から始まっている。術後早期は、多量の下痢により水分、電解質を失うため、中心静脈カテーテルを用いて静脈栄養による栄養投与と下痢によって失った水分、電解質を十分に補充する必要がある。経腸栄養は可及的早期に開始し、静脈栄養に伴う合併症に留意しながら管理していく必要がある。失った腸管の部位や長さにより、PN離脱後も栄養吸収障害による問題を認めることがあるため、長期にわたる経過観察を行っていくことが重要である。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2012&ichushi_jid=J03242&link_issn=&doc_id=20121001190007&doc_link_id=10.11244%2Fjjspen.27.1203&url=https%3A%2F%2Fdoi.org%2F10.11244%2Fjjspen.27.1203&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：Japanese   Publisher：(株)南山堂  

＜Key Points＞◎小児は細胞外液の比率が高く、容易に体液バランスの異常をきたしやすい。◎維持輸液量、欠乏量、喪失量を考えて輸液療法の計画を立てる。◎軽度の脱水では経口補液療法を用いることがある。(著者抄録)

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Authorship：Lead author   Language：Japanese   Publishing type：Article, review, commentary, editorial, etc. (trade magazine, newspaper, online media)   Publisher：(株)東京医学社  

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Authorship：Lead author   Language：Japanese   Publishing type：Article, review, commentary, editorial, etc. (scientific journal)   Publisher：(株)東京医学社  

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Language：Japanese  

J-GLOBAL

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Language：Japanese  

J-GLOBAL

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Language：Japanese   Publisher：(株)東京医学社  

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Language：Japanese   Publisher：(株)東京医学社  

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Language：Japanese   Publisher：金原出版(株)  

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Presentation type：Poster presentation  

Venue：Sapporo   Country：Japan  

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